Failure to Maintain Fall Mat Intervention for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident identified as high risk for falls. The resident was admitted with multiple diagnoses including adult failure to thrive, unspecified lack of coordination, and weakness, and was documented on an annual assessment to have severe cognitive impairment. Nursing progress notes show that on one occasion the resident experienced a witnessed fall at the bedside after rolling out of bed onto the floor, as reported by his roommate and the resident himself. A subsequent risk management report documents another incident in which the resident was found lying on his right side on the floor at the bedside, with a fall mat in place, and the resident reported he had rolled over while in bed. The resident’s care plan identified him as high risk for falls due to a history of falling and poor safety awareness, and included an intervention initiated after the first fall to place a floor mat at the bedside while in bed, which was revised following the second fall. During a surveyor observation, the resident was seen lying in bed on his left side facing the wall, with no fall mat located next to his bed or elsewhere in the room, despite the care plan intervention requiring a floor mat. A CNA interviewed shortly afterward stated the resident required two staff for a stand-and-pivot transfer, was not aware of the resident’s previous falls out of bed, and did not know that a fall mat was supposed to be in place. An RN confirmed that the resident should have a floor mat next to the bed and, upon observing the room, acknowledged that no mat was present. The DON stated that it is the responsibility of nursing and management to ensure fall interventions are in place. The facility’s accidents and supervision policy states that the resident environment will remain as free of accident hazards as possible and that each resident will receive adequate supervision and assistive devices to prevent accidents, including implementing and monitoring interventions to reduce hazards and risk.
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