F0656

D

Failure to Develop and Implement Fall Risk Care Plan for High-Risk Resident

Glendale, California Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The facility failed to develop and implement a comprehensive person-centered care plan addressing fall risk for a resident who was at high risk for falls. The resident was admitted with diagnoses including diabetes mellitus, a left below-knee amputation, and was receiving dialysis. An MDS dated 3/3/2026 showed the resident was cognitively intact with a BIMS score of 15, and required substantial/maximal assistance for personal hygiene, dressing, toileting hygiene, and putting on/taking off footwear, and partial/moderate assistance with oral hygiene and eating. A Fall Risk Evaluation dated 2/20/2026 was completed, but the MDS Coordinator later stated it was wrongly coded and that the resident was actually at high risk for falls. The DON also stated that the fall risk evaluation showed a high-risk fall score of 16.

On 2/20/2026 at approximately 9:00 PM, the resident called for help and staff found the resident on the floor in a kneeling position next to the end of the bed, facing the bathroom, unable to get up without assistance and reporting severe left hip pain. A Change of Condition Evaluation documented this event at 10:03 PM. A subsequent hospital orthopedic surgery history and physical dated 2/22/2026 indicated the resident had sustained a left intertrochanteric femur fracture after the injury on 2/20/2026. During interviews, the MDS Coordinator confirmed that no fall risk care plan had been completed for this resident despite the high fall risk, and the DON confirmed that a care plan for risk of falls should have been completed. The facility’s policy on comprehensive person-centered care stated that care plan interventions are to be based on thorough assessment and are intended to prevent or reduce decline in residents’ functional level.