F0656

D

Failure to Implement Post-Fall Care Plan Interventions for Three Residents

Sonoma, California Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves nursing staff failing to implement care plan fall-prevention interventions for three residents after falls occurred. For the first resident, admitted with muscle weakness, repeated falls, and diastolic heart failure, the fall risk assessment form was largely blank, making it unclear whether the resident was identified as a fall risk upon admission, despite a history of three or more falls in the prior three months and a recent hospitalization. The resident’s care plan dated 1/20/26 identified fall risk and required staff to place fall mats by the bed. After an unwitnessed fall on 1/22/26 during a transfer from a bedside commode to bed, and a subsequent fall on 2/13/26 while attempting to stand and use a urinal that resulted in a nasal fracture, orbital fractures, and a brain bleed, the care plan was revised on 2/13/26 to include fall mats by the bed and initiation of a toileting schedule. However, during observation on 2/27/26, no fall mats were present by this resident’s bed, and the Assistant Director of Nursing and Administrator could not provide documentation that a toileting schedule had been implemented as ordered in the revised care plan.

For the second resident, admitted with muscle weakness, a history of falling, and a transient cerebral ischemic attack, a progress note documented an unwitnessed fall in the bathroom, where the resident was found on her side next to the toilet with a cut to the left forehead. The resident’s fall risk care plan, initiated on 7/25/24 and revised on 2/10/26 following the fall, required staff to provide a bedside commode to assist with safe toileting. A subsequent care plan dated 2/9/26, addressing an actual fall, directed staff to ensure the resident wore non-skid footwear during all walking activities. During observation on 2/27/26, no bedside commode was present at the resident’s bedside or in the bathroom, and the resident confirmed that a commode had not been placed in the room. Instead, a pair of well-worn household slippers with very slippery soles and no grip was observed near the bed, and the resident stated she wore those slippers when getting out of bed and when walking, contrary to the care plan requirement for non-skid footwear.

For the third resident, admitted with atherosclerosis of the aorta and age-related osteoporosis, progress notes dated 2/10/26 documented that the resident was found on the floor next to the bed with a skin tear to the right cheek and multiple abrasions to the upper back. The resident’s care plan dated 5/16/25 identified fall risk and required nursing staff to keep the call bell within reach to meet goals of being free from falls and avoiding serious injury. A revision on 2/12/26 added an intervention for staff to place fall mats on the left side of the bed. During observation on 2/27/26, the resident was in bed and the call light was not within reach; the resident could not locate it, and it was later found tucked under the blanket and pillow on the right side. Additionally, no fall mats were present on either side of the bed, despite the care plan directive. During interviews, staff reported that fall risk status and interventions were communicated in shift report and on printed reports, and that fall interventions should include low beds, call lights within reach, and fall mats, but the Administrator acknowledged he could not say how often care plans were actually used by staff. The facility’s written policy on falls and accident prevention required investigation of each fall and implementation of actions to reduce or prevent additional falls and minimize potential for injury, but the specified care plan interventions for these three residents were not carried out as written.