Failure to Implement Ordered Fall Mat Interventions per Care Plan
Penalty
Summary
The facility failed to implement a care plan intervention for a resident with a history of an actual fall. The resident’s comprehensive care plan, initiated on 12/13/25 with a focus on a prior fall, specified the intervention of placing fall mats on both sides of the bed when the resident was in bed. During an observation and concurrent interview and record review on 12/17/25 at 1:52 p.m., the resident was observed in bed with only one fall mat at the bedside. The LVN present confirmed that the care plan required fall mats on both sides of the bed but acknowledged that only one mat was in place. Review of the facility’s Fall Prevention policy, approved 11/4/09, indicated that all residents are considered at risk for falls and that the care plan should incorporate goals and interventions to provide an optimal safe environment, but the specific fall mat intervention in this resident’s care plan was not fully implemented. This failure to follow the resident’s individualized fall prevention care plan constituted the deficiency identified by the surveyors.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.