F0656

D

Failure to Implement and Clearly Specify Fall Mat Intervention in Care Plan

Artesia, New Mexico Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s development and implementation of an accurate, comprehensive care plan for a resident with fall risk needs. The resident was admitted on a documented admission date, and the care plan, last revised on 03/31/25, included an intervention to offer a fall mat as indicated. During observation on 02/22/26 at 2:26 pm, the resident was seen lying in bed while the fall mat was stored underneath the bed rather than positioned for use. In a subsequent interview at 2:37 pm, an RN confirmed that the fall mat was not placed correctly and should have been on the floor next to the bed. Later, on 02/26/26 at 2:54 pm, the DON confirmed that the recommended use of the fall mat was for it to be placed on the floor next to the resident’s bed when the resident was in bed and further acknowledged that the care plan was not person-centered and did not specify the exact recommendations for fall mat use.

This failure to both clearly specify and consistently implement the fall mat intervention in accordance with the resident’s care plan constituted the cited deficiency.