Failure to Provide Fall Mats as Ordered for High-Risk Residents
Penalty
Summary
The facility failed to ensure that fall mats were present for two residents identified as high risk for falls, as ordered by their physicians and outlined in their care plans. One resident, who had a history of confusion, gait and balance problems, and paralysis, was care planned to have a fall mat present when in bed. Multiple observations revealed that the fall mat was not present while the resident was in bed, and this was confirmed by the resident's daughter, a CNA, the Director of Rehab, and the DON, all of whom acknowledged that a fall mat should have been in place. Similarly, another resident with a physician order for a fall mat to be present when in bed was observed lying in bed without the required fall mat. This absence was confirmed by the Scheduler and the DON, both of whom stated that a fall mat should have been present according to the physician's order. These findings were based on direct observations, interviews with staff and family, and review of care plans and physician orders.