Failure to Provide Required Fall Prevention Devices for Resident at Risk
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's environment was free from accident hazards and that adequate supervision and assistive devices were provided to prevent accidents. Specifically, a resident with severe cognitive impairment, a history of multiple falls, and a moderate fall risk was observed to have only one floor mat in place beside her bed, despite her care plan and physician's orders requiring two mats as a safety precaution. The resident's care plan and medical orders had been updated following several unwitnessed and witnessed falls, including one with injury, to include the use of two floor mats. Staff interviews confirmed that all staff, including CNAs and nursing staff, were responsible for ensuring the mats were in place, and that the absence of a mat could result in injury. The LVN acknowledged the resident was supposed to have two mats and was unsure why the second mat was missing, noting that the supply clerk was responsible for providing mats. The Administrator and DON also confirmed the requirement for two mats and stated that the main responsibility for ensuring their presence fell on the nurse caring for the resident. Facility policy required individualized fall prevention interventions based on assessed risk, which was not followed in this instance.