F0656

D

Failure to Implement Fall-Prevention Care Plan Intervention

Dinuba, California Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The facility failed to implement a care plan intervention for a resident identified as being at risk for falls following a fall incident. According to the interdisciplinary team Post Fall Review dated 2/3/26, the resident experienced an unwitnessed fall at approximately 1:47 p.m., was found on the floor bleeding, and was observed lying on her right side in a cradle position. The Post Fall Review documented a recommendation for nonskid tape at the bedside. The resident’s care plan dated 2/4/26 identified her as at risk for falls related to poor balance and included an intervention for nonskid tape at the bedside, initiated on that date.

During an observation and interview in the resident’s room on 2/9/26 at 11:43 a.m. with the DON, the resident was seen lying in bed covered with a blanket, and there was no nonskid tape at the bedside as required by the care plan. The DON stated that the nonskid tape should have been placed at the bedside right away. The facility’s policy on developing and implementing care plans with the interdisciplinary team states that interventions are the specific actions or services each discipline will provide to help the resident meet their goals, but the ordered intervention of nonskid tape at the bedside was not implemented for this resident.