F0656

G

Failure to Develop and Implement Individualized Fall-Prevention Care Plan for Cognitively Impaired Walker User

Long Beach, California Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement an individualized, comprehensive fall-prevention care plan for a resident who used a front-wheeled walker (FWW) and had cognitive impairment. The resident was admitted and later readmitted with diagnoses including schizoaffective disorder, bipolar disorder, dementia, and abnormality of gait. An MDS assessment documented severely impaired cognitive function for daily decision-making and a need for supervision with self-care and mobility, including sitting, standing, and walking, with use of a walker. Physical therapy evaluations and treatment notes showed that the resident was being followed by PT for mobility, gait training, and education on safe FWW use, and that the resident used a FWW as an assistive device and required supervision for transfers and gait.

Despite these identified needs and the resident’s use of a FWW, record review showed there was no fall risk or FWW-related care plan in place prior to the fall event. The facility’s fall risk assessments scored the resident as low risk (scores of 2 and later 5, with >10 indicating high risk), and the DON later stated these assessments did not accurately reflect the resident’s fall risk. The facility’s policies on Care Planning–Interdisciplinary Team, Safety and Supervision of Residents, and Resident Mobility and Range of Motion required the IDT to develop individualized care plans based on comprehensive assessments, identify fall and mobility risks, and include specific, measurable interventions, goals, and responsibilities. However, the IDT did not meet to develop a care plan addressing the resident’s fall risk or the need to consistently use the FWW for ambulation, and no such care plan was found in the medical record before the incident.

On the night of the fall, nursing notes documented that staff observed the resident walking in the hallway without the FWW, then suddenly running and falling onto the left side. The resident reported not knowing what happened and initially described mild left hip pain, for which ibuprofen was administered. Staff notified the physician, who ordered a stat left hip x-ray and safety monitoring every 30 minutes for 72 hours. The MAR showed ibuprofen was later given for severe left hip pain. The x-ray revealed an acute fracture of the left femur, and the resident was transferred to a general acute care hospital, where ED and orthopedic records confirmed a left femur fracture due to a mechanical fall and documented subsequent left hip hemiarthroplasty. Interviews with nursing staff, the DON, and the resident indicated that the resident knew she needed the FWW but forgot to use it, had periods of confusion, and that staff who saw her ambulating without the FWW should have intervened. The DON and other staff acknowledged that a fall-prevention care plan with interventions such as reminders to use the FWW and environmental safety measures should have been in place and implemented before the fall occurred, but it was not.