Failure to Include Fall Mat Intervention in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including dementia, generalized muscle weakness, lack of coordination, mood disorder, type 2 diabetes, and chronic kidney disease. The resident was identified as high risk for falls, with a fall risk evaluation score of 13 and a BIMS score of 2 indicating severe cognitive impairment. Despite a history of multiple falls resulting in injuries such as a laceration to the back of the head and a skin tear, the care plan did not include the use of a fall mat, even though one was observed in place next to the resident's bed. The care plan interventions focused on call light accessibility, appropriate footwear, monitoring for pain or injury, therapy evaluation, and offering activities, but omitted documentation of the fall mat as an intervention. Interviews with facility leadership, including the ADON and DON, revealed uncertainty about whether the fall mat was in use and acknowledged that if it was being used, it should have been included in the care plan to ensure staff awareness and consistent implementation. The facility's policy required that care plans incorporate identified problem areas and be revised as residents' conditions change, but this was not followed in the case of the fall mat intervention for this resident. The omission of the fall mat from the care plan was identified through observations, interviews, and record review.