Failure to Implement Care-Planned Fall Prevention Interventions
Penalty
Summary
The facility failed to implement a comprehensive, person-centered care plan intervention for a resident identified as high risk for falls. The facility’s policy on comprehensive person-centered care plans required that services be furnished to attain each resident’s highest practicable well-being. Medical record review showed that after an unwitnessed fall on 1/28/26, when the resident was found lying face down on the side of the bed, the resident’s care plan for risk of falls was updated to include bilateral floor mats as an intervention to minimize injury in case of falls. A Morse Fall assessment documented a score of 65, with scores of 45 and above indicating high fall risk, confirming the resident’s elevated risk status and the need for fall-prevention interventions such as floor mats. On 2/17/26, observation of the resident revealed a round hematoma on the forehead and dark purple bruising on both cheeks, chin, and the front of the neck. During this observation, no floor mats were present in the room or on the floor next to the resident’s bed, despite the care plan intervention specifying bilateral floor mats. In a subsequent interview, the resident stated that the bump on the forehead was from a fall that occurred at the facility. During a concurrent observation and interview, an LVN confirmed that the resident did not have floor mats in place and stated that there should be floor mats due to the resident being a fall risk. The Administrator and DON later acknowledged these findings, confirming that the care-planned intervention for bilateral floor mats had not been implemented.
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