Failure to Ensure Fall Mat Placement for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with a history of repeated falls, dementia, and quadriplegia was observed without a fall mat placed alongside his bed, as required by his care plan. The resident's care plan specifically included the intervention of ensuring a fall mat was positioned next to the bed to prevent injury from falls. During an observation, the fall mat was found folded and leaning against the foot of the bed while the resident was lying in bed, and a bedside table was positioned over him. Interviews with the ADON and DON confirmed that the fall mat should have been in place while the resident was in bed, as he was considered a fall risk. Both staff members indicated that Hospice staff may have forgotten to reposition the fall mat after providing care. The facility's policy on fall management requires identification of residents at risk for falls and implementation of interventions, such as the use of a fall mat, to manage those risks. The failure to ensure the fall mat was in place constituted a lapse in maintaining an environment free from accident hazards for the resident.