Failure to Remove Trip Hazard for Ambulatory Resident
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically by not removing a fall mat that posed a trip hazard. The resident, an elderly female with a history of stroke, non-Alzheimer's dementia, muscle weakness, and moderately impaired cognition, was able to self-transfer to her bedside commode and wheelchair. Despite her ability to ambulate short distances, a fall mat was kept on the floor next to her bed at all times, with three wheels of her bedside table resting on it, making it difficult for her to move the table and increasing her fear of tripping. Both the resident and her family expressed concerns about the mat being a trip hazard, but staff insisted it remain in place as a fall prevention measure. Multiple staff interviews confirmed that the fall mat was kept in place continuously, regardless of the resident's mobility, and that the family’s requests to remove it were denied. The physical therapist noted that fall mats could be a trip hazard for ambulatory residents and recommended they be removed when not in use. The facility's care plan and policy emphasized providing a safe environment free from hazards, but the mat's placement contradicted this by creating a potential obstacle during transfers. The resident had not experienced recent falls, but the persistent use of the fall mat, despite voiced concerns and observed difficulties, constituted a failure to maintain an environment free from accident hazards.