F0657

D

Failure to Update Fall Risk and Transfer Care Plan Leading to Assisted Fall

Los Angeles, California Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to update and revise a resident’s fall risk and transfer care plan to reflect current assessments and needs. The resident was admitted with diagnoses including muscle wasting and atrophy, lack of coordination, and end-stage renal disease. A care plan dated 11/12/2025 identified a deficit in activities of daily living and required two staff for transfers using a Hoyer lift with a medium sling. A Lift Transfer Reposition assessment dated 1/22/2026 documented that the resident could not transfer independently or with supervision without a device, was unable to bear at least 50% weight on one or both legs, and required a total (Hoyer) lift with a medium sling. Nursing documentation on the same date noted bilateral leg weakness and fall risk factors, including a history of falls within six months.

A subsequent MDS dated 1/29/2026 indicated the resident was alert and oriented with good recall, and was dependent for sit-to-stand and chair/bed-to-chair transfers, requiring assistance of two or more helpers. A physical therapy note dated 1/31/2026 also documented that the resident was dependent with 100% assist or two or more helpers for sit-to-stand and chair/bed-to-chair transfers. However, a Restorative Nursing Weekly/Monthly Progress Report dated 2/24/2026 stated the resident’s function was improving and that the resident could sit and stand with one-person assist using a gait belt. Despite the earlier assessments indicating dependence and need for a total lift, the care plan in effect on 2/26/2026 still listed the resident as at risk for falls/injury due to impaired mobility with interventions including two-person transfers using a Hoyer lift, and this intervention was not created until 2/27/2026, after the assisted fall.

On 2/26/2026, the resident experienced an assisted fall while being transferred from a wheelchair to a bed by a CNA using a gait belt with one-person assist. The CNA reported that this one-person gait belt transfer was the usual practice, that the resident was not on fall precautions, and that she was only aware of the second fall. The LVN also stated the resident was a one-person transfer with a gait belt and not on fall precautions. The DON later acknowledged that the Lift Transfer Reposition assessment on readmission indicated the need for a total Hoyer lift and that this status should have been updated in the care plan at admission/readmission, and also stated that the care plan had not been updated after a prior fall on 12/23/2025. Facility policies required that comprehensive care plans be developed within seven days of the comprehensive assessment and be reviewed and revised as the resident’s condition changed, including after significant changes and at least quarterly, but the resident’s fall risk and transfer care plan was not updated to reflect current assessments and prior falls before the assisted fall occurred.