Failure to Maintain Fall Prevention Intervention for High-Risk Resident
Penalty
Summary
A deficiency occurred when staff failed to ensure that a fall mat, an intervention identified in the care plan, was consistently in place for a resident with a history of falls, hemiplegia, hemiparesis, cognitive impairment, and other significant medical conditions. The resident's care plan specifically required a fall mat at bedside due to her poor balance, unsteady gait, and history of falls. On the day of observation, the fall mat was initially in place, but a Certified Occupational Therapy Assistant (COTA) moved it to access the resident and did not return it to its proper position before leaving the room. Subsequent observation confirmed the fall mat was not in place, and the COTA acknowledged forgetting to replace it. Interviews with staff, including a CNA, the DON, MDS nurses, and the ADON, confirmed that the fall mat was a required intervention for this resident and that failure to have it in place could result in injury. The resident had previously experienced a fall resulting in a laceration and emergency room visit. Facility policy required that interventions to reduce accident risks, such as fall mats, be implemented as documented in the care plan. The failure to ensure the fall mat was in place represented a lapse in following the resident's individualized safety interventions.