Failure to Initiate Fall Prevention Care Plan After Resident Re-admission With Hip Fracture
Penalty
Summary
Surveyors identified a deficiency in care planning when the facility failed to develop a fall awareness and fall prevention care plan for a resident upon re-admission. Record review showed that on 12/17/25 the resident was found by a CNA lying on her back on the hallway floor, complaining of lower extremity pain, and was sent to the hospital for evaluation. The resident was re-admitted on 12/22/25 with diagnoses including fracture of the left femur, hip fracture, muscle weakness, kidney disease, and age-related osteoporosis. Nursing progress notes documented the re-admission with a left hip fracture diagnosis. During interviews and concurrent record reviews with a licensed nurse and the DON on 1/7/26, both confirmed that the resident’s clinical record did not contain a fall care plan. The licensed nurse stated that a fall care plan was important for resident safety and was part of the facility’s protocol after a fall. The DON stated that the care plan was used by all staff as a guide for resident care and acknowledged that the absence of a care plan meant nursing staff lacked guidance about the resident’s care. The DON also stated she expected staff to have initiated a fall care plan due to the resident’s fall history and risk of falls. Review of the facility’s Falls Management policy indicated that the facility’s process included evaluating, managing, and reducing falls, with licensed nurses documenting interventions and monitoring responses, but this was not implemented for the resident following re-admission.
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