Failure to Implement Care Plan Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement care plan interventions related to fall prevention for one resident identified as being at risk for falls. Facility policy on Fall Management, revised 05/05/23, requires that residents at risk for falls be identified, that care be planned, and that interventions be implemented and reflected on the care plan, with individualized interventions reassessed and revised as needed. The resident had diagnoses including dementia, history of falling, diabetes mellitus, hypokalemia, chronic kidney disease, and urinary tract infection, and a Quarterly MDS showed a BIMS score of 3/15, indicating severe cognitive impairment. The same MDS documented that the resident required maximum assistance for bed mobility, was dependent for toilet transfers, and had no falls since admission or prior assessment. The resident’s care plan, initiated 05/29/2024, identified impaired cognitive function and risk for falls related to dementia, decreased mobility, history of falls, impaired vision, and impaired cognition, and included interventions such as maintaining a safe environment with even, clutter-free floors, nursing monitoring during ambulation in the hall, encouraging the resident to wait for assistance before ambulating, use of a fall mat at bedside, reminders to call for assistance with the call bell prior to transfers and ambulation, and staff education. A Fall Incident Report dated 10/19/2025 documented that the resident had a history of falling, was bed bound, required a Hoyer lift and two-person assist for transfers, and had a last fall on 10/24/2024. On two separate observations on 02/11/2026, the resident was seen in bed asleep with the bed in the lowest position, periodically pulling herself up using top bedrails, and no fall mats were in place despite the care plan intervention. In an interview, the DON stated that the care plan and MDS were not updated, that there had been only one MDS nurse who was behind, that there was currently no MDS nurse on staff, and that unit managers were trying to update MDS and care plans daily; the DON also acknowledged that the fall was not documented in the care plan and that interventions should have been put in place based on submitted statements.
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