F0689

D

Inaccurate Fall Risk Assessment and Non-Individualized Care Planning

Fresno, California Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure an accurate fall risk assessment for a resident on admission, which led to the resident being categorized as a moderate rather than a high fall risk. The resident was admitted with diagnoses including an unspecified acetabular fracture, abnormalities of mobility and gait, and a history of falling. An MDS assessment showed a BIMS score of 7/15, indicating severe cognitive impairment. The resident’s Functional Abilities Collaboration documented that the resident was dependent on staff for all ADLs, including bathing, hygiene, transfers, and bed and chair mobility, and required two-person assistance for transfers.

On admission, the LVN supervisor completed a Fall Risk Assessment (FRA) that assigned the resident a score of 14, placing him at moderate fall risk. During later interviews and record review, the LVN acknowledged that the FRA was completed inaccurately. She stated that she left the bed rail question incomplete, did not correctly answer the medication-related question, and inaccurately documented the resident’s continence status. The DON also stated that the medications the resident was taking placed him at a higher risk for falls, that the bed rail question was left unanswered despite the resident having one side rail, and that these errors meant the resident should have been categorized as high risk for falls instead of moderate.

The inaccurate fall risk assessment directly affected the development of the resident’s fall risk care plan. The MDS nurse stated that the care plan interventions were based on the fall risk assessment, diagnosis history, and ADL status, and that the interventions included were basic and not individualized to the resident’s needs. The MDS nurse further stated that because the fall risk assessment incorrectly indicated a moderate fall risk, the care plan interventions were also inaccurate and not properly tailored to the resident’s specific risks, including his medication regimen, diagnoses, bed rail use, and safety needs. Facility policies on comprehensive person-centered care plans and fall risk management required that assessments be thorough, ongoing, and used to derive individualized interventions based on identified risk factors such as history of falls, multiple medications, gait and balance disorders, cognitive impairment, and environmental hazards.

The resident experienced a fall on the morning of 11/15/25, when staff found him on the floor resting on his left side with his feet slightly under the bed and arms at his sides, able to move all extremities without noted pain or gross misalignment at that time. The IDT Fall Progress Note described the resident as presenting with unpredictability and attempting to function beyond ADL limitations. The ADON stated that the resident required two-person assistance for transfers, but it appeared only one CNA was assisting him when he fell. The DON and MDS nurse both stated that the inaccurate fall risk assessment could have contributed to potential interventions not being utilized and to the inability of nursing staff to properly identify individualized interventions required to prevent falls and injury, linking the inaccurate assessment and care planning to the circumstances surrounding the resident’s fall.