Failure to Implement Care-Planned Bilateral Floor Mats for High Fall-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention requiring bilateral floor mats at the bedside for a resident assessed as high risk for falls. The resident was admitted with dementia and lack of coordination, and a subsequent MDS assessment documented severe cognitive deficit and a need for maximal assistance with walking, transfers, and toileting. The resident’s care plans for risk of falls related to impaired mobility and weakness, initiated on 10/26/2025, specified that the bed may be in the lowest position with bilateral floor mats while in bed and that floor mats should be applied next to the bed as appropriate. A Fall Risk Evaluation dated 12/10/2025 showed a score of 16, indicating the resident was at high risk for falls. During observation on 1/23/2026, the resident was found lying in bed with the bed in a low position, a bed alarm in place, and only one fall mat located on the right side of the bed. In a concurrent interview and record review, an LVN confirmed that the resident’s fall risk care plan called for bilateral fall mats and stated the resident needed mats on both sides of the bed to prevent injuries in the event of a fall. The DON also stated that fall mats needed to be in place on both sides of the bed and, upon entering the room, found the left fall mat placed against the wall toward the right side of the bed rather than positioned on the floor beside the bed. The facility’s policy on Person Centered Care Planning required development and implementation of a comprehensive person-centered care plan, but the specified intervention of bilateral floor mats was not implemented as written.
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