Failure to Ensure Proper Placement of Fall Mats for Resident with Fall Risk
Penalty
Summary
Facility staff failed to ensure that fall mats were properly positioned for a resident with a history of falls and a diagnosis including seizures. The resident was admitted in March 2025 and had experienced a fall on 4/19/25, after which a care plan was initiated specifying that fall mats should be placed on the floor at the bedside while the resident was in bed. On two separate observations on 6/25/25, the fall mat intended for the left side of the resident's bed was found turned and placed against the wall at the head of the bed, rather than next to the bed as required by the care plan. The Unit Manager confirmed that the fall mat was not in the correct position and acknowledged that the resident was supposed to have fall mats next to the bed at all times.