F0689

D

Failure to Revise Fall Prevention Care Plan After Repeated Falls in a High-Risk Resident

Temple City, California Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to keep a resident as free from accident hazards as possible and to provide adequate supervision to prevent accidents, particularly related to falls. The resident had a history of multiple falls prior to admission from an assisted living facility, with 3–4 emergency room visits in a two‑week period, and was admitted with diagnoses including unspecified dementia, difficulty in walking, and Non‑Hodgkin lymphoma. A History and Physical dated 11/15/2025 documented that the resident did not have the mental capacity to understand and make medical decisions. A Morse Fall Scale completed on 12/3/2025 showed a score of 105, indicating high fall risk. The resident’s care plan, initiated on 10/17/2025, identified high risk for falls due to confusion, gait/balance problems, psychoactive drug use, and unawareness of safety needs, with goals for the resident to remain free of falls and injury and interventions including anticipating and meeting needs and following the facility fall protocol.

Despite these identified risks, the facility did not adequately update or individualize the care plan after repeated falls. On 12/28/2025, a post‑fall assessment documented that the resident fell while attempting to get out of bed to go to the bathroom and was found with no apparent injury and assisted to the bathroom. However, no new interventions were added to the high‑risk falls care plan after this fall. On 1/7/2026, another post‑fall assessment indicated the resident slipped when attempting to get up to use the bathroom, and progress notes documented an open cut to the bridge of the nose with bruising, requiring transfer to a general acute care hospital and repair of the laceration with Dermabond. The resident was also treated for a UTI and then readmitted to the facility the same day.

Further assessments and staff interviews showed that the resident remained severely cognitively impaired and dependent for most ADLs, including toileting and walking short distances, yet continued to attempt to get up and use the bathroom without calling for assistance. The MDS dated 1/20/2026 documented severe cognitive impairment and substantial/maximal assistance needs for toileting and mobility. Nursing staff, including an LVN and RN supervisor, reported that the resident never called for help, frequently tried to get up without telling anyone, believed she could still move normally despite weakness, and often got up at night to use the bathroom without assistance. The DON acknowledged that although the resident could use the call light, she chose not to, and that an intervention for frequent visual checks was not entered on the resident’s care plan, despite the facility’s policy requiring care plans to be re‑evaluated and modified with significant changes in status. The resident subsequently experienced additional falls, including a fourth fall from standing on 1/21/2026 resulting in a left hip fracture and the need for surgical hemi‑arthroplasty, followed by a decline in ADL function from walking 10 feet to no longer walking after readmission.