F0689

D

Failure to Maintain Fall Mat and Locked Wheelchair Brakes for High-Risk Resident

Cedar Park, Texas Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and use of required assistive devices to prevent accidents for one resident. The resident was an adult male with schizoaffective disorder, COPD, repeated falls, vascular dementia, muscle wasting and atrophy, and anxiety disorder. His quarterly MDS showed a BIMS score of 14, indicating no cognitive impairment, and documented that he required partial/moderate assistance for bed mobility and was dependent for bed-to-chair transfers. He had a documented history of falls without injury, including falls on 01/17/2026 and 01/20/2026, after which the care plan and Kardex were updated to include a fall mat at bedside, bed in lowest position, and maintaining a clear pathway free of obstacles due to his fall risk related to vascular dementia and incontinence.

On the survey date, observations at 2:29 PM and 3:20 PM showed the resident in bed with the bed in a low position and his wheelchair placed at the left side of the bed, but with both wheelchair brakes unlocked and no fall mat present on either side of the bed, despite the care plan and Kardex requiring a fall mat at bedside when he was in bed. During interview, the resident reported he had falls in the past and now asked for help to get in and out of bed. Review of the Kardex dated 01/23/2026 confirmed that a fall mat was to be implemented at bedside for safety.

Multiple staff interviews confirmed that facility practice and resident-specific interventions required a fall mat at bedside when the resident was in bed and that wheelchair brakes should be locked when the wheelchair was at bedside. CNAs and nursing staff (CNA A, RN B, LVN C, CNA D, CNA E) described fall prevention as including bed in low position, call light within reach, use of fall mats at bedside for residents identified as fall risks, and locking wheelchair brakes to prevent the chair from moving if a resident attempted to sit or transfer. The DON, ADON, and ADM all stated that the resident had an increase in falls, that fall mats were an intervention in place for him, that this was communicated via the care plan and Kardex, and that the resident should have a fall mat whenever he was in bed and wheelchair brakes locked at bedside. Despite these documented interventions and staff knowledge, the resident was observed in bed without a fall mat and with wheelchair brakes unlocked on the day of survey.