Failure to Implement Care Planned Fall Mats for At-Risk Residents
Penalty
Summary
The facility failed to ensure that fall prevention interventions, specifically fall mats, were in place for two residents identified as being at risk for falls. Both residents had documented histories of falls and were care planned for fall prevention measures, including the use of fall mats while in bed. On the date of observation, both residents were found in bed without their fall mats in place; instead, the mats were folded and leaning against furniture in their rooms. Staff interviews revealed a lack of awareness and communication regarding the implementation of fall mats. One healthcare aide was unaware that a fall mat was required for a resident and was unsure to whom the mat belonged. Another CNA acknowledged that fall mats were part of the care plan but was not aware that the mat was not in place after the resident returned from physical therapy. The LVN confirmed that both residents required fall mats and was unaware that the mats were not implemented at the time of observation, despite routine rounding to check fall prevention measures. The Director of Nursing confirmed that both residents had care plans requiring fall mats and acknowledged the failure to implement these interventions. The facility's policy required individualized, person-centered interventions, including assistive devices and adequate supervision, to reduce risks related to environmental hazards. The lack of implementation of care planned fall mats for these residents constituted a failure to provide adequate supervision and assistance devices to prevent accidents.