Failure to Implement Physician Order for Bilateral Floor Mats
Penalty
Summary
A deficiency occurred when the facility failed to implement a physician's order for floor mats to be placed on both sides of a resident's bed. The resident, who had diagnoses including Alzheimer's disease, dementia, and a history of repeated falls, was assessed as having severely impaired cognitive skills and required substantial to maximal assistance with activities of daily living and was dependent for mobility. During observation, only one safety mat was found on the left side of the bed, despite the physician's order and care plan specifying floor mats on both sides to prevent injury in the event of a fall. Interviews with facility staff, including an LVN and the DON, confirmed that the physician's order for bilateral floor mats was not followed. The care plan and job descriptions for both LVNs and RNs indicated the requirement to comply with physician orders and implement care plans. The failure to place floor mats on both sides of the bed was directly observed and verified through record review and staff interviews.