Failure to Maintain Safe and Homelike Environment Due to Torn Floor Mat
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for one resident by not ensuring that the resident's left floor mat was free from tears. The resident, who had a history of cerebral infarction resulting in hemiplegia and hemiparesis, as well as schizophrenia, was admitted with a physician's order for bilateral floor mats for safety due to a high risk of falls. During observations, the left floor mat was found to have three L-shaped tears on the top, and the overbed table was placed on top of the mat. Both a Licensed Vocational Nurse and the Director of Nursing confirmed that floor mats should be free from tears and that staff are responsible for notifying maintenance to replace any equipment in disrepair. The resident's medical records indicated a need for assistance with all activities of daily living and a cognitive impairment, further emphasizing the importance of a safe environment. Despite facility policy requiring a safe, clean, and homelike environment, the torn floor mat remained in use, which was acknowledged by staff as not meeting the standard for resident comfort and safety. The deficiency was identified through observation, interviews, and record review.