Failure to Maintain Hazard-Free Environment and Conduct Post-Fall Analysis
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards for four residents reviewed for accidents. Specifically, three residents who were at high risk for falls and had orders for bilateral floor mats were found to have equipment or furniture, such as side tables and trash cans, placed on top of their fall mats. Observations confirmed that these objects were present on the mats in the residents' rooms, and interviews with nursing staff, including the ADON and DON, confirmed that this practice was contrary to both manufacturer instructions and facility policy. Staff acknowledged that placing heavy objects on the mats could damage them and reduce their effectiveness in absorbing the impact of a fall, potentially leading to injury if a resident were to fall onto the mat. Additionally, the facility failed to conduct an interdisciplinary team (IDT) root cause analysis after one resident experienced a fall. The resident, who had a history of Alzheimer's disease and was at high risk for falls, was found sitting on a landing mat after an unwitnessed fall. Record review and staff interviews revealed that no IDT post-fall conference or analysis was conducted for this incident, despite facility policy requiring such a review to identify potential hazards and evaluate risks following a fall. Staff, including the ADON, Quality Assurance Nurse, and DON, confirmed that the IDT review was missed and should have been completed to ensure appropriate interventions were in place. Facility policies reviewed indicated a commitment to maintaining a hazard-free environment and required that environmental hazards, such as obstacles in the footpath and improper use of fall mats, be addressed through ongoing staff training, monitoring, and QAPI processes. The policies also specified that the IDT should analyze assessment and observation data to identify accident hazards and develop individualized care plans. Despite these policies, the facility did not adhere to its own procedures in the cases identified, resulting in increased risk of accidents and injuries for the residents involved.