Failure to Ensure Fall Mat Use for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide an environment free from accident hazards and did not ensure the use of assistive devices as required for a resident with a history of falls and significant physical and cognitive impairments. The resident, a male with hemiparesis, muscle weakness, and moderate cognitive impairment, was assessed as unsteady on his feet and required assistance from two staff members. His care plan specifically included the use of fall mats when in bed to prevent injury from potential falls. During an observation, the resident was found in bed without the fall mat in place as required; instead, the mat was at the foot of the bed. The resident acknowledged the purpose of the fall mat and his tendency to forget his limitations. A CNA confirmed that the fall mat had not been placed due to an oversight during shift change and incomplete rounds. The DON stated that it was expected for all high-risk residents to have fall mats in place when in bed, in accordance with the facility's fall prevention policy.