Failure to Maintain Hazard-Free Environment Due to Improper Use of Fall Mat
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by not maintaining the proper use of fall/floor mats. Specifically, a resident with hemiplegia, hemiparesis, muscle weakness, and impaired cognition, who required substantial assistance with mobility and ADLs, had a physician's order for a floor mat to be placed on the right side of the bed to decrease potential injury. During observation, it was found that a side table and a trash can were placed on top of the resident's floor mat. Both a CNA and the DON confirmed that no objects should be placed on top of the floor mat, as this defeats its purpose and can cause injury if the resident falls. Review of the resident's care plan and facility policies indicated interventions and requirements to maintain a safe, hazard-free environment, including specific instructions for the use of floor mats. The DON acknowledged that staff did not follow facility policies and user instructions for the floor mat, which are intended to reduce the incidence and severity of resident trauma by ensuring the mat is unobstructed. The failure to keep the floor mat free from furniture and equipment constituted a deficiency in providing a safe environment for the resident.