Failure to Implement Care-Planned Bedside Fall Mat for High-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of a comprehensive, person-centered care plan for one resident with a history of falls. The resident was an elderly male with dementia, respiratory failure, spinal stenosis, heart disease, and diabetes, who was severely cognitively impaired with a BIMS score of 01, always incontinent of bowel and bladder, had a recent fall, used a wheelchair for mobility, and was completely dependent on staff for transfers, toileting, showers, and dressing. His comprehensive care plan, dated 12/26/2025, documented an actual fall with no injury and included specific fall-prevention interventions such as a floor mat, anticipating needs, and ensuring the call light was within reach. On two separate observations on the same day, the resident was seen resting comfortably in bed with his call light within reach, but no floor mat was present at the bedside despite it being a listed care plan intervention. An interview with the LVN assigned to the resident confirmed that he had fallen about a month prior and that his fall precautions included a fall mat, which she stated should have been at the bedside; she was unsure why it was not in place and acknowledged it was her responsibility to ensure its presence. The DON and the Administrator both stated that the resident had a fall and that a bedside floor mat while resting in bed was one of the interventions, and each affirmed that it was the bedside nurse’s responsibility to ensure the mat was present. The Administrator also stated there was no specific fall mat policy but that she expected all interventions listed on the comprehensive care plan to be implemented, consistent with the facility’s written policy requiring development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables.
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