F0656

D

Failure to Individualize and Implement Care Plan for Fall Prevention and Feeding Assistance

El Cajon, California Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop, revise, and implement an individualized, person-centered care plan addressing supervision, fall prevention, and feeding assistance for a high fall-risk resident with intellectual developmental disability and severe cognitive deficits. The resident’s MDS documented that he was rarely or never understood and had severe cognitive impairment, and he had a known history of falls prior to admission. Despite this, the fall-risk care plan initiated on 12/22/25 contained only generic interventions such as educating/reminding the resident to call for assistance, keeping the call light within reach, and keeping the resident within supervised view “as much as possible,” without tailoring these interventions to the resident’s inability to understand or reliably use the call light or recognize danger. The DSD stated that this care plan was not individualized or specific to the resident’s cognitive and safety needs and that relying on the call light alone was insufficient given his decreased safety awareness and limited understanding.

On the day of the fall, multiple staff interviews showed that the resident’s high fall-risk status and need for close supervision were not consistently communicated or incorporated into his care plan. CNA 1, who was assigned to the resident, reported that she was not informed the resident was a fall risk and therefore did not arrange for supervision when she left the area to use the restroom. She stated she had observed the resident independently wheeling himself in the hallway and had provided a meal tray, watching him eat independently, and that he remained seated in his wheelchair unsupervised in the hallway until approximately 8 p.m., when he was later found on the floor with a bleeding head wound. CNA 2, who worked on the same unit but was not assigned to the resident, also stated she was not informed the resident was a fall risk, observed him sitting alone in his wheelchair appearing confused, and did not recognize the need for close supervision. In contrast, CNA 3, a registry CNA, stated she had been informed by LNs at the start of the shift that the resident was a fall risk and had observed him attempting to stand from his wheelchair, but she reported that CNA 1 did not instruct her to monitor or supervise the resident before leaving for the restroom.

Licensed nursing staff interviews further demonstrated that the resident’s supervision needs were not translated into an updated, individualized care plan or clear staff assignments. LN 1, the nursing supervisor on duty, stated he had verbally directed CNAs on the hallway to closely monitor the resident because he was a high fall-risk, had repeatedly attempted to get out of his wheelchair, and required close supervision at all times, including 1:1 supervision for safety. However, he acknowledged that there were no physician orders for 1:1 supervision and that the resident was not care-planned for 1:1 supervision, even though he believed this should have been done. LN 2 stated she was not aware the resident was identified as a fall risk prior to the incident, but given his IDD, confusion, and communication deficits, he should have been considered a safety and fall risk and the care plan should have been updated with interventions such as 1:1 supervision. The DON stated her expectation that staff complete a comprehensive safety assessment, personalize safety needs based on cognitive impairment and decreased safety awareness, and implement structured monitoring with clearly assigned staff responsibility, and acknowledged that failure to clearly communicate the fall risk and lack of supervision resulted in inadequate monitoring and hospitalization.

The deficiency also includes failure to implement the resident’s nutritional care plan for feeding assistance. The resident’s nutritional care plan, initiated on 12/22/25, specified 1:1 feeding assistance, and a speech evaluation from the same date documented severe swallowing abilities, prior 1:1 feeder treatment, and aspiration risk. The facility’s feeding list included the resident’s name, and CNA 5 stated that although the resident could physically feed himself, he was on her feeder list due to difficulty swallowing and to prevent choking hazards. Despite these documented needs, CNA 1 reported that she provided the resident with a meal tray and watched him eat independently, indicating that 1:1 feeding assistance as outlined in the care plan was not followed. The DSD stated that staff were required to communicate resident-specific risks and care needs, including feeding assistance, through shift handoff reports and nurse-led huddles before providing care, and that failure to communicate these risks could result in preventable injuries such as choking. The DON stated that assigned staff were required to provide direct assistance during feeding due to choking risk and not leave the resident unattended, and that failure of staff to understand and follow the resident’s specific risks and care needs placed him at risk for injury, further health decline, and death.