Failure to Implement Care-Planned Fall Prevention Interventions
Penalty
Summary
Surveyors identified that the facility failed to implement fall care plan interventions for a resident with a history of falls. The resident was an elderly female admitted with dementia, walking difficulty, and a vertebral fracture, and the facility’s fall log documented two prior falls for her, on 5/10/25 and 8/19/25, both without injury. Her fall care plan included an intervention for a floor mat on the side of the bed. However, on 12/2/25 at 10:22 AM, she was observed in bed with the floor mat folded and stored behind the headboard instead of being placed at the bedside as care-planned. In an interview on 12/3/25 at 1:57 PM, the DON stated that staff should follow care plan interventions and that the floor mat should be at the bedside when a resident at risk for falls is in bed. The facility’s written guidelines for incidents/accidents/falls stated that, based on the results of an incident/accident/fall, the resident’s care plan will be addressed to ensure needed points of focus have measurable goals with appropriate interventions in place. This failure to follow the established fall care plan intervention for the resident with a documented fall history constituted the deficiency related to ensuring the area was free from accident hazards and that adequate supervision and assistance devices were provided to prevent accidents.
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