F0689

D

Failure to Care Plan and Document Adequate Supervision for High Fall-Risk Resident

Bronx, New York Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and proper care planning to prevent accidents for a resident with severely impaired cognition and a high fall risk. The resident had diagnoses including malignant neoplasm of the prostate, anemia, non-Alzheimer’s dementia, and depression, and was assessed as high risk for falls. The facility’s fall prevention and visual check policies required identification of fall risk, interdisciplinary care planning with specific strategies for fall prevention, and scheduled room checks (hourly on day/evening shifts and every 30 minutes on night shift). The CNA Kardex for this resident called for supervision/oversight at least once every hour. Despite these policies and assessments, the resident’s care plan did not document supervision interventions or monitoring frequencies related to fall prevention until after a fall in early January.

Between late November and early January, the resident experienced five separate fall events. On each occasion, the resident was found on the floor in or near their room or ambulating in the hallway and lowering themself to the floor. The accident reports consistently documented that there were no visible injuries, though the resident intermittently complained of pain and underwent multiple diagnostic imaging studies, which showed osteopenia, scoliosis, spondylosis, and degenerative changes but no fractures. After each fall, the facility’s internal documentation referenced plans such as reminding the resident to ask for assistance, using the call bell, keeping the bed in the lowest position, and maintaining half-hour visual checks through purposeful rounding. However, review of the resident’s care plan and monitoring logs showed that these supervision and monitoring interventions (hourly or half-hourly checks) were not actually reflected in the written care plan during the period when the falls occurred.

Interviews with staff and the resident’s emergency contact further demonstrated the lack of documented, individualized supervision in the care plan despite repeated falls. The emergency contact reported multiple complaints to facility staff about the recurring falls and the absence of updated instructions in the care plan, stating they received no clear explanation for the incidents and believed the facility was unable to provide adequate supervision. CNAs and RNs stated that the resident was considered high risk for falls, was monitored hourly or more frequently, and was sometimes kept in the day room or observed more often when restless, but they acknowledged that increased monitoring (e.g., every 30 minutes or more frequently) was not specifically ordered or documented. Nursing supervisors and the DON confirmed that although the resident was on hourly monitoring during day and evening shifts and half-hour monitoring at night, these monitoring frequencies and supervision interventions were not implemented in or reflected by the resident’s care plan until after the last documented fall, resulting in a failure to ensure that the resident received adequate, care-planned supervision to prevent accidents.