Failure to Develop Person-Centered Fall Prevention Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes to address fall and safety risks for three residents. For a male resident with Alzheimer’s disease, muscle weakness, unsteadiness on his feet, and a severely impaired BIMS score of 6, the MDS identified him as at risk for falls. His care plan, last revised on 1/06/2026, noted fall risk related to unsteady gait, decreased balance, medications, poor safety awareness, use of a mobility device, and need for assistance with transfers, but lacked person-centered fall interventions despite documented falls on 3/23/2024, 7/28/2024, and 1/13/2026. A female resident with cellulitis of the abdominal wall, late-onset Alzheimer’s disease, reduced mobility, and need for assistance with personal care had an MDS BIMS score of 13, indicating intact cognition, and was coded as a fall risk. Her care plan, also last revised on 1/06/2026, similarly identified generic fall risk factors and assistance needs but did not include a person-centered plan to address her falls, despite 17 falls between 8/13/2025 and 12/27/2025. Another female resident with sepsis, repeated falls, obesity, and muscle weakness had an MDS BIMS score of 8, indicating moderate cognitive impairment, and was coded as a fall risk. Her care plan, last revised on 1/06/2026, documented fall risk factors and assistance with transfers but did not provide individualized, measurable fall-prevention strategies, even though she experienced 45 falls over the prior 12 months.
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