Failure to Remove Floor Mat Creates Tripping Hazard Leading to Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's environment was free from accident hazards, specifically regarding the improper placement of a floor mat. One resident with a history of falls, dementia, amnesia, and a previous hip fracture was found sitting on the floor between her bed and her roommate's bed after a fall. The resident was unsupervised at the time and was wearing rubber shoes. A nurse responding to the incident observed a floor mat placed between the beds, which is contrary to facility policy, as floor mats should only be placed at the bedside when residents are in bed and removed when residents are ambulating to prevent tripping hazards. The nurse noted a swelling on the right side of the resident's head following the fall. The resident's care plan identified her as being at risk for falls due to impaired cognition, unsteady gait, and a history of falling. The roommate also had a care plan indicating high fall risk, with an intervention for floor mats to be used only when in bed. Facility policy and staff interviews confirmed that floor mats left on the floor when residents are ambulating pose a tripping hazard. The incident occurred when the floor mat was not removed as required, directly contributing to the resident's fall and injury.