Failure to Implement Bilateral Fall Mat Intervention per Care Plan and Physician Order
Penalty
Summary
The facility failed to implement a person-centered comprehensive care plan for a resident at risk for falls. Observations on multiple occasions showed that the resident, who was visually impaired, had poor safety awareness, gait and balance problems, used psychotropic medications, had a history of falls, and was weak, did not have bilateral floor mats placed on both sides of the bed as required. Instead, only one floor mat was placed on the left side of the bed, while the mat for the right side was folded and stored under the bed. The resident's physician order and care plan both specified that floor mats should be present on both sides of the bed while the resident was in bed. Staff confirmed that the mat was not placed on the right side because the resident only got up on the left side, despite the care plan and physician order requirements. The DON acknowledged that physician orders must be followed and that mats should be on both sides.