F0656

D

Failure to Implement and Update Fall-Prevention Care Plan Interventions

Cedar Park, Texas Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s development and implementation of a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple diagnoses, including schizoaffective disorder, COPD, repeated falls, vascular dementia, muscle wasting, and anxiety disorder. The resident’s quarterly MDS showed a BIMS score of 14, indicating no cognitive impairment, and documented that he required partial/moderate assistance for bed mobility and was dependent for chair/bed transfers, with a history of falls without injury. The care plan dated 01/21/2026 documented falls on 01/17/2026 and 01/20/2026 and included an intervention, dated 01/19/2026, to implement a fall mat at the bedside and keep the bed in the lowest position, and the Kardex also reflected a fall mat intervention under the safety section.

Despite these documented interventions, observations on 01/23/2026 at 2:29 PM and 3:20 PM showed the resident in bed with the bed in a low position, his wheelchair placed at the bedside with both brakes unlocked, and no fall mat present on either side of the bed. The incident report for the 01/17/2026 fall indicated the resident was found on the floor after attempting to get to his wheelchair, and that the IDT met and added fall mats as an intervention and updated the care plan. However, the comprehensive care plan was not updated to include locking the wheelchair brakes when the resident was not in the wheelchair, even though this was a relevant intervention following the fall where the resident attempted to reach his wheelchair.

Interviews with CNAs and nursing staff confirmed that fall prevention practices at the facility included keeping beds in low position, ensuring call lights were within reach, locking wheelchair brakes when the wheelchair was at bedside, and using fall mats next to the bed when residents were in bed. Staff reported that they determined fall risk and interventions, such as fall mats, from the Kardex and care plan. The DON and ADM stated that the resident had an increase in falls and that fall mats were an intervention for this resident, and that the Kardex was triggered by the care plan. However, on the day of observation, staff interviews and room observations showed that the fall mat intervention documented in the care plan and Kardex was not implemented, and the specific intervention to ensure wheelchair brakes were locked when the resident was not in the wheelchair was not added to the resident’s comprehensive care plan after the fall on 01/17/2026, resulting in a failure to fully develop and implement a comprehensive person-centered care plan consistent with identified needs.