Failure to Care Plan and Implement Ordered Floor Mats for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan that reflected a physician’s order for floor mats for a resident at high risk for falls. The resident had diagnoses including cognitive impairment and lack of coordination, and assessments documented severe cognitive impairment, inability to make decisions, and a need for substantial to maximal assistance with bed mobility and transfers. Following an unwitnessed fall on 8/11/2025, a Change of Condition assessment and Fall Risk Evaluation identified the resident as high risk for falls. A physician order dated 8/11/2025 directed that floor mats be placed on either side of the resident’s bed, and an IDT review on 8/12/2025 recommended floor mats at the bedside to reduce injury risk. Subsequent Change of Condition assessments on 8/18/2025 and 12/17/2025 documented two additional unwitnessed falls at the bedside. On observation on 1/15/2026, no floor mats were present on either side of the resident’s bed. A CNA reported that the resident was at risk for falls due to a history of falls and frequent attempts to get out of bed unassisted, and stated she usually removed the floor mat during the day shift and was unsure if staff replaced it in the evening. One LVN stated the resident had a history of falls and attempts to get out of bed unassisted, could not recall recent use of floor mats, and was not aware of any floor mat orders, adding that floor mats should be care planned so all staff would know they were needed. Another LVN confirmed the resident had orders for floor mats on either side of the bed and that he was responsible for ensuring physician orders were carried out, but he did not recall checking for floor mats that morning and acknowledged there was no care plan for floor mat use. The facility’s care plan policy stated that the care plan was to be used in developing the resident’s daily care routines and be available to staff responsible for providing care or services.
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