Failure to Ensure Call Bell Accessibility and Fall Mat Implementation
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for one resident with significant medical conditions, including paraplegia, spinal stenosis, muscle contractures, and blindness in one eye. The resident was found on the floor after an unwitnessed fall, with the call bell not activated and out of reach, partially under the bed. Staff interviews confirmed that the resident was capable of using the call bell, but it had not been placed within reach after staff assisted the resident back into bed following the fall. Three staff members exited the room without ensuring the call bell was accessible to the resident. Additionally, the resident's care plan, updated after the fall, required fall mats to be placed on both sides of the bed. However, during a subsequent observation, no fall mats were present, and staff confirmed that the intervention had not been implemented. The mats had been removed by housekeeping for cleaning and were not returned to the resident's room before the resident's return. These failures resulted in the environment not being free from accident hazards and lacking adequate supervision and interventions to prevent further accidents.