Failure to Implement Fall-Prevention Care Plan After Room Change
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive care plan for a resident at risk for falls. The resident had multiple diagnoses, including a left femur neck fracture, seizures, difficulty walking, diabetes, dementia, and an impulse disorder. A Quarterly MDS with an ARD of 12/11/25 documented severe cognitive impairment, with a BIMS score of 6/15, and two or more falls since admission or the prior assessment. On observation, the resident was seen in a wheelchair equipped with anti-rollback brakes, rear anti-tip bars, and a drop seat, and the resident’s bed was in a low position with a standard mattress and the left side of the bed against the wall. Non-skid strips were not observed on the floor at the bedside. The resident’s care plan identified them as being at risk for falls and included specific interventions such as non-skid strips at the bedside, initiated on 2/2/25, and an edge defined perimeter mattress, initiated on 7/25/24. However, these interventions were not in place at the time of the surveyor’s observation. In an interview, the DON stated that care plans were reviewed quarterly by the MDS nurse and that falls care plans were reviewed by the IDT after a fall. The DON explained that the resident had a room change in October 2025 and acknowledged that the resident’s interventions, including the non-skid strips and edge defined perimeter mattress, were not moved to the new room, despite Unit Managers being responsible for ensuring all interventions were in place after a room change.
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