F0689

D

Failure to Implement Ordered Floor Mats for High Fall-Risk Resident

Burbank, California Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to implement ordered fall-prevention interventions for a resident assessed as high risk for falls. The resident was admitted with diagnoses including muscle weakness, history of falling, and cerebral infarction, and had a fall risk score of 11, indicating high fall risk. Physician orders dated 2/24/2026 directed the use of a low bed and floor mat to decrease potential injury, and the care plan for fall and injury risk instructed staff to utilize safety and supportive devices as ordered and provide adequate supervision and safety cues. The facility’s Falls and Fall Risk, Managing policy stated that staff will identify interventions based on evaluations and current data to prevent falls and minimize complications.

On 3/4/2026, during observation of the resident’s room, surveyors noted a yellow star behind the bed indicating the resident was a fall risk and should have a low bed and floor mats in place, but no floor mats were present. The resident reported a history of falls but did not recall having a mat by the bed. The Infection Preventionist confirmed that the star signified the need for a low bed and floor mats and acknowledged that the absence of floor mats was not following the plan of care and could lead to a fall with possible injury. The Director of Staff Development stated the resident uses two landing mats and confirmed that at the time of observation the mats were not in the room and that the mats are intended to prevent injury when a resident falls. The Administrator also confirmed the resident had an order for floor mats, was a fall risk, and should have floor mats while in bed, and that without them there was potential for a fall resulting in injury or fracture.