Failure to Provide Fall Mats as Required in Care Plan
Penalty
Summary
Facility staff failed to implement a required fall prevention intervention for a resident with multiple risk factors for falls and injury. The resident, who had diagnoses including psychotic disorder, depression, hypertension, anorexia, dementia with behavioral disturbance, and dysphagia, was assessed as having severely impaired cognitive skills and a history of falls. The resident's care plan, revised days prior to the survey, specified the use of bilateral fall mats as an intervention for fall and injury prevention. However, during multiple observations, the resident was found in bed without fall mats in place. Interviews with the certified nurse's aide and registered nurse revealed a lack of awareness and communication regarding the care plan requirement for fall mats, resulting in the intervention not being implemented as directed.