Failure to Implement Fall-Prevention and Toileting Care Plan for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a complete, measurable care plan addressing fall prevention and incontinence/toileting needs for a cognitively impaired resident at high risk for falls. The resident, admitted in February 2025 with dementia, cerebral infarction, difficulty walking, and severely impaired cognition (BIMS score of 3), required substantial assistance with toileting, hygiene, and ambulation, used a wheelchair, and progressed from occasional to frequent incontinence of bowel and bladder. Despite these documented needs and changes in continence status on multiple MDS assessments, the Resident Care Plans dated 6/12/25, 9/24/25, and 12/9/25 did not include adequate goals and interventions for incontinence care or a specific toileting plan/schedule, even though facility policy required urinary assessments and toileting plans based on continence status. The facility also failed to consistently implement an established fall-prevention intervention requiring gripper (non-skid) socks while the resident was in bed. The care plan identified the resident as at risk for falls due to impaired balance and unsteady gait and directed that gripper socks be applied while in bed, with the 12/9/25 plan further directing staff to check placement of gripper socks at the beginning of the 11 PM–7 AM shift. However, the Certified Nurse’s Aide care card dated 11/20/25 only indicated the resident was continent and included transfer assistance and ensuring non-skid socks were in place, without a toileting schedule. Nursing assistants interviewed reported they were unaware the resident required gripper socks while in bed and described applying regular socks instead. Over the review period, the resident experienced multiple unwitnessed falls, including being found on the bathroom floor with a skin tear to the left elbow, on the room floor with a tipped wheelchair and complaints of pain, next to the bed after ambulating without assistance, and under the bathroom sink with skin tears and reported rib and back pain. A later fall investigation documented that the resident fell out of bed while attempting to use a urinal and was not wearing gripper socks at the time. Interviews with nursing assistants and the DNS confirmed that the resident should have had a toileting plan/schedule due to severe cognitive impairment and incontinence patterns, and that NAs were expected to review care cards for updated care needs, but the care card and care plans did not reflect a specific toileting schedule or fully implemented fall-prevention interventions.
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