Failure to Implement Fall-Prevention Care Plan Intervention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care plan intervention for a resident assessed as high risk for falls. The resident is an adult male with medical diagnoses including acute respiratory failure, tracheostomy, schizoaffective disorder, and epilepsy, and a BIMS score of 10/15. A fall assessment dated 5-17-2025 scored the resident at 15, indicating high fall risk. The resident’s care plan dated 7-3-2025 included an intervention to keep the bed in the lowest position. However, nursing notes dated 12-25-2025 documented that the resident’s bed was left in an elevated position, and the nurse observed the resident lying on his left side, after which he was sent emergently to a local hospital for evaluation. During interviews, the DON stated that on 12-25-2025 at 5:50 AM, the resident was observed on the floor after the bed had been left in a high position, and that the care plan required the bed to be in a low position due to the resident’s high fall risk. The DON reported not knowing who left the bed in the high position and stated an expectation that nursing staff implement care plan interventions. The Restorative Nurse confirmed that staff are responsible for implementing care plan interventions and did not know why the bed was left high. The Administrator also stated an expectation that nursing staff follow and implement the care plan to ensure the resident’s safety. The facility’s Comprehensive Care Plan policy dated 3-2025 states that the comprehensive care plan should drive the care and services provided for the resident.
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