Failure to Maintain Safe and Homelike Environment Due to Damaged Floor Mats
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for two residents by not ensuring that their floor mats, which are intended to prevent injury from falls, were free from rips, peeling, and disrepair. For one resident with Alzheimer's disease, dementia, and depression, the floor mat next to the bed was observed to have peeling edges and was in disrepair. Staff interviews confirmed that the mat should have been replaced, as its condition was not homelike and could affect the resident's quality of life. The care plan for this resident included keeping the environment free of hazards and maintaining floor mats as interventions to minimize falls or injury, but these interventions were not properly implemented. Another resident, who had a history of falls, impaired vision, moderately impaired cognition, and required assistance with mobility and ADLs, also had a fall mat with peeling covers at the edges. Staff, including the Director of Staff Development and the DON, acknowledged that the mat's compromised condition could reduce its effectiveness in preventing injury and did not provide a homelike environment. The resident's care plan specifically aimed to ensure a homelike environment, but the presence of a damaged mat was inconsistent with this goal. Facility policy required maintaining a homelike environment and ensuring the quality of life for all residents, and manufacturer specifications for the mats included instructions to avoid damage. Despite these guidelines, the facility did not ensure that the floor mats for these two residents were maintained in good condition, resulting in a deficiency related to the residents' right to a safe, clean, comfortable, and homelike environment.