F0656

D

Failure to Implement Fall Prevention Care Plan for High-Risk Resident

Concord, California Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The facility failed to implement a comprehensive, person-centered care plan for one of five sampled residents by not providing the supervision specified in the resident’s fall care plan. The resident had a diagnosis of Alzheimer’s disease and a BIMS score of 0/15, indicating severe cognitive impairment. A fall risk assessment identified the resident as high risk for falls and injury due to unsteady gait with use of a front wheel walker, advanced age, incontinence, distraction, altered perception of surroundings, disorganized speech, restlessness, lethargy, varying mental function, wandering, abusive behavior, and resistance to care, with 1–2 falls in the prior 90 days. The resident’s fall care plan, reviewed on 2/7/25, documented that the resident was at high risk for falls related to confusion, gait/balance problems, incontinence, and unawareness of safety needs, and included an intervention that staff would monitor and assist the resident while ambulating in the patio.

Despite this care plan intervention, the facility did not provide supervision to the resident while she was on the facility’s patio. As a result, the resident fell to the ground, sustaining a cut and bump to the back of the head and required transfer to an acute care hospital for further care and evaluation. During interview, the DON stated that the fall could have been avoided if a staff member had been on the patio with the resident as specified in the care plan. The facility’s policy on comprehensive, person-centered care plans required development and implementation of care plans with measurable objectives and timetables to meet residents’ physical, psychosocial, and functional needs, but this was not followed for this resident in relation to patio supervision.