Failure to Maintain Call Bell Access and Fall Mats for High-Fall-Risk Resident
Penalty
Summary
Facility staff failed to ensure that fall prevention interventions, specifically fall mats and the call bell, were properly in place for a resident with a documented history of repeated falls and prior fall-related injuries. The resident had been in the facility since 2017 and had diagnoses including a non-displaced right humerus fracture, primary osteoarthritis, obsessive-compulsive disorder, unspecified dementia, and repeated falls. The medical record showed the resident sustained a fall on 9/28/25 resulting in a head hematoma with laceration, and another fall on 10/23/25 resulting in a right humerus fracture. A 11/20/25 health status note documented that the resident was discussed in a risk management meeting related to falls and that a perimeter mattress and fall mats would be implemented. The resident’s care plan for fall risk included keeping the call light within reach at all times while in the room, educating the resident to use the call bell when getting out of bed, and placing fall mats on both sides of the bed as tolerated. Despite these documented interventions, multiple observations over several days showed that staff did not maintain the call bell within the resident’s reach and did not ensure fall mats were in place next to the bed. On 1/6/26 at 2:37 PM, 1/7/26 at 8:58 AM, and 1/8/26 at 8:38 AM, the resident was observed lying in bed with the call bell wrapped around the back, bottom of the quarter side rail and lying on the floor, not within reach. On 1/7/26 at 8:58 AM, there were no fall mats on the floor next to the resident’s bed; instead, a single fall mat was folded in half by the doorway, while the resident’s bed was by the window. The DON, present during one of the observations, acknowledged that the call bell was not supposed to be on the floor. The Medical Director was informed of the resident’s falls and the observations that the call bell was not within reach and the fall mat was not on the floor next to the bed.
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