F0656

D

Failure to Implement and Document Post-Fall, Person-Centered Care Plans

Modesto, California Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for three residents following unwitnessed falls and changes in condition. For one resident with COPD, peripheral vascular disease, anal canal cancer with colostomy, and dementia, the resident experienced an unwitnessed fall after slipping on spilled water in her room, resulting in a left hip fracture and subsequent hip hemiarthroplasty. Although the resident returned from the hospital with a new post-operative condition and reported ongoing hip pain, there was no care plan developed or implemented to address her post-surgical needs. The Director of Nursing and the admitting RN both stated that a care plan should have been implemented upon readmission and after the change in condition, but it was not.

For a second resident with COPD, schizophrenia, orthostatic hypotension, and unsteadiness on feet, the facility failed to follow the existing care plan interventions after an unwitnessed fall. The resident’s post-fall evaluation documented a high fall risk, and the care plan called for neuro checks for 72 hours after the fall. However, only the initial neuro check entry was found in the electronic medical record, and the remaining neuro checks from subsequent days could not be located in either paper or electronic form. The DON confirmed that if the documentation could not be located, the neuro checks were not completed. Additionally, although the IDT met to discuss the fall, there was no IDT note documented in the record to show that the team had met and addressed the incident.

For a third resident with COPD, schizophrenia, muscle weakness, lung cancer, cervical disc disorder with radiculopathy, and unsteadiness on feet, the facility did not document implementation of care plan interventions following an unwitnessed fall. The resident’s post-fall evaluation showed a high fall risk, and the IDT note described an unwitnessed fall where the resident was found sitting on the floor by the bed with no observed skin injuries and decreased urine output, leading to further assessment and transfer to the ER. The care plan specified frequent rounding every two hours to check for pain, placement, position, and toileting needs. However, the facility could not produce documentation that staff checked on the resident every two hours as required. The DON, CNAs, and Medical Records Director all acknowledged that such checks should be documented in the EMR, but they were unable to locate any record of when the resident was last checked, indicating that the care plan interventions were not documented as carried out.

The facility’s own policies on fall risk assessment, care plan goals and objectives, interdisciplinary care planning, and charting and documentation require resident-centered fall prevention plans, measurable care plan goals with timetables, IDT-developed comprehensive care plans, and complete and accurate documentation of services and changes in condition. Despite these policies, the facility did not complete required fall risk scoring for one resident’s post-fall evaluation, did not implement a new care plan after a significant surgical event, did not complete or retain required neuro check documentation for another resident after an unwitnessed fall, and did not document two-hourly monitoring for a third resident as specified in the care plan. These actions and omissions led to the cited deficiency for failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for the affected residents.