Failure to Implement Fall Mat Intervention for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to implement a care plan intervention for a resident with dementia and hypertension, who was assessed as severely cognitively impaired and dependent on staff for bed mobility. The resident's care plan, last revised on 7/9/25, included the use of a fall mat on the left side of the bed as a fall precaution. However, during multiple observations on 9/8/25 and 9/10/25, the fall mat was not in place as directed by the care plan; instead, it was found rolled up in the bathroom. The resident was observed positioned in the center of the bed, with the bed in the low position, and was reported by her representative and staff to be able to roll in bed. Interviews with the unit manager and nursing assistants revealed a lack of awareness regarding the fall mat intervention. The unit manager was unaware that the fall mat was not in place and could not explain why it had been removed. One nursing assistant was not aware that a fall mat was required, while another, who provided care almost daily, had not seen the fall mat in use and reported that the resident had attempted to get out of bed in recent months. The DON also confirmed he was not aware the fall mat was not in place and stated it should have been on the floor as per the care plan.