Failure to Secure Mattress Overlay Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a resident was provided with an environment free from accident hazards, specifically by not properly securing the resident's mattress overlay. The resident, who had a history of stroke with left-sided weakness, dysphasia, aphasia, and required a tracheostomy, was totally dependent on staff for all activities of daily living and was assessed as a high fall risk. Despite care plan interventions requiring safe and proper positioning in bed on her air mattress, the mattress overlay was not properly secured, as one of the straps was left unfastened. This oversight resulted in the resident sliding off the bed along with the unsecured mattress overlay, as captured in video footage provided by the family. The incident occurred while the resident was lying in bed and subsequently fell headfirst onto a fall mat beside the bed. Nursing documentation confirmed the resident was found on the floor with the overlay, and no immediate injuries were observed. The family was notified and requested hospital evaluation, where the resident was diagnosed with a urinary tract infection and returned to the facility the same day. Interviews with staff revealed that the overlay had previously been found unsecured and that it was the responsibility of nurses and CNAs to ensure overlays were properly attached. The DON acknowledged that the required fall risk assessments were not completed as scheduled or after the fall event. The facility's policy required fall risk assessments on admission, quarterly, and after any fall, but these were not conducted as required for this resident.