Failure to Provide Fall Mat for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident assessed as high fall risk. The resident, who had a history of traumatic brain injury, major depressive disorder, and repeated falls, was observed in bed on two occasions without a fall mat in place, despite care plan interventions specifying the need for a floor mat while in bed. Record reviews showed the resident had multiple unwitnessed falls in the preceding months and was assessed as high fall risk. The care plan included several fall prevention interventions, including the use of a floor mat, but there was no physician order for a fall mat, and staff were unaware of the requirement. Interviews with facility staff, including a CNA, the resident's nurse practitioner, the DON, and the administrator, confirmed that a fall mat was expected and appropriate for the resident's safety. The CNA was unaware of the need for a fall mat and did not see any instructions in the charting system. The nurse practitioner and DON both stated that a fall mat should have been in place due to the resident's frequent falls and high risk status. Facility policy required individualized care plans for high-risk residents, including interventions to address identified risk factors, but the intervention was not implemented as required.