F0689

D

Failure to Follow Care Plans for Fall Mats and Two-Person Transfers

Eugene, Oregon Survey Completed on 01-20-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility did not consistently follow an established fall-prevention care plan for a resident with dementia and a history of rolling out of bed. The resident’s care plan, initiated in early December, required padded fall mats on both sides of the bed whenever the resident was in bed. On multiple observations over several days in January, the resident was seen in bed without a fall mat on the left side, or with the left fall mat placed away from the bedside or folded and leaning against the foot of the bed. A CNA confirmed the resident was at risk for falls and should have fall mats on the floor next to the bed while in bed, and a LPN Resident Care Manager stated the resident had previously rolled out of bed and was care planned for fall mats on both sides, with the expectation that staff follow the care plan.

Surveyors also found that staff failed to follow a care plan requiring two-person assistance for transfers for a resident with a history of stroke and weakness. The resident’s care plan documented a need for two-person assistance with transfers using a front-wheeled walker. A fall investigation from July showed that a CNA, after providing a shower, assisted the resident to stand and transfer using the walker without a second staff member, during which the resident’s legs weakened, balance was lost, and the resident slid or fell to the floor. The CNA stated she did not review the care plan before performing the transfer, and the investigation and root cause analysis identified that the resident was a two-person assist and the CNA did not check the care plan. The LPN notified of the incident and facility leadership later acknowledged that the resident was care planned as a two-person transfer and that staff were expected to review the care plan before providing care.