Failure to Provide Required Fall Prevention Equipment for At-Risk Resident
Penalty
Summary
A deficiency occurred when a resident, who was assessed as being at risk for falls and had moderate cognitive impairment, was observed in bed without the required bilateral floor mats in place. The resident's medical record included a physician's order and a care plan intervention to have bilateral floor mats at the bedside for safety precautions, due to the resident's inability to understand and make decisions, as well as left-sided weakness and total dependence for all ADLs. Despite these documented interventions, staff confirmed during interviews and observations that no floor mats were present at the bedside. Further review and interviews revealed that the CNA and RN were aware of the resident's physical limitations and the order for floor mats, but the mats were not in place. The RN indicated that the physician should have been notified to discontinue the order if the intervention was no longer appropriate, but this had not occurred at the time of the observation. The DON was informed and verified the findings.
Plan Of Correction
IDT will review all residents with order for floor mats quarterly to ensure it is still appropriate for the resident and update plan of care accordingly. Department heads and designee will do room rounds daily to make sure floor mats were in place for residents with orders for 3 months. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025 F0690 1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 12, 63, and 89 were affected by this deficient practice. Immediately, licensed nurse put a basin underneath the indwelling catheter bag to prevent it from touching the floor. For resident 89, on 7/17/2025, RN updated the plan of care for the resident to include indwelling catheter care in the resident's order. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents with indwelling catheters were potentially affected by this deficient practice. On 7/17/2025, RN supervisor and unit manager audited all residents with indwelling catheters to ensure they have an order for indwelling catheter care and that no indwelling bag was touching the floor, with no other issues noted. On 8/5/2025-8/8/2025, DON in-serviced all licensed nurses and CNAs about facility policy and procedure for indwelling catheter care, in particular making sure residents with indwelling catheters have an order for indwelling catheter care to prevent residents from developing UTI and to update the plan of care. DON also emphasized ensuring all indwelling catheter bags and medical tubing were not touching the floor. 3. Measures that will be put into place or systematic changes the facility will make to ensure that the deficient practice does not recur: DON or designee will oversee this process. Unit manager and designee will review all new admissions and re-admissions to make sure residents with indwelling catheters have an order for indwelling catheter care. IDT will review during clinical meetings to ensure the plan of care for residents with indwelling catheters is being followed. Medical Records will audit all new admissions and re-admissions to verify that residents with indwelling catheters have updated care plans. Any noncompliance will be reported to the DON for three months.