F0656

D

Failure to Implement Care-Planned Fall Mats for a High Fall-Risk Resident

Shreveport, Louisiana Survey Completed on 03-16-2026

Penalty

Fine: $12,735

Summary

The facility failed to implement a comprehensive, person-centered care plan intervention for a resident identified as a fall risk. The resident, admitted on 07/03/2025, had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, other lack of coordination, Alzheimer's disease, and muscle weakness. The resident’s comprehensive care plan documented, as of 10/22/2025, that fall mats were to be placed on each side of the bed when the resident was in bed. However, observations on 03/09/2026 at 8:27 a.m. and again at 2:20 p.m. showed the resident in bed or in the room without fall mats in place on either side of the bed. During interview at 2:20 p.m., a CNA confirmed that the resident’s room did not have fall mats in place. At 3:05 p.m., the ADON acknowledged that the care plan included the intervention of a fall mat, and a subsequent observation at 3:10 p.m. with the ADON again confirmed that no fall mats were present in the resident’s room despite the care plan requirement.

This deficiency centers on the discrepancy between the documented fall-prevention intervention in the resident’s care plan and the lack of implementation of that intervention as evidenced by multiple observations and staff confirmations on the same day.