Failure to Implement and Document Fall Risk and Post-Fall Care Plan Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement and document comprehensive, person-centered fall risk and post-fall care plan interventions for one resident. The resident was admitted with diagnoses including progressive cognitive decline with anxiety, generalized muscle weakness, insomnia, impaired communication, and gait and mobility abnormalities. An MDS dated 12/25/25 showed memory impairment on the BIMS and two or more falls since the prior assessment. SBAR forms dated 4/15/25, 4/28/25, 5/3/25, 7/24/25, 10/3/25, and 10/12/25 documented six fall incidents in 2025. Fall risk evaluations from 3/4/25 to 12/12/25 showed scores ranging from 10 to 20, confirming the resident was at high risk for falls. The resident’s care plan, initiated 3/5/25 for high fall risk, included specific interventions such as verifying and documenting the resident’s location every two hours, offering toileting every two hours while awake after a fall on 7/24/25, and performing a root cause analysis of past falls with documentation of possible root causes and education of the resident, family, caregivers, and IDT. Additional post-fall care plans initiated on 1/26/26 and 1/28/26 directed staff to continue fall-risk interventions and obtain a PT evaluation after an unwitnessed fall with serious injury. During interviews, the Administrator confirmed the facility could not produce documentation that the root cause analysis was performed, that the resident’s location was monitored and toileting was offered every two hours, or that a PT evaluation was completed as ordered in the care plan. The facility’s own person-centered care planning policy required development and implementation of a comprehensive care plan describing services to attain or maintain the resident’s well-being, but documentation of implementation of the specified interventions was absent.
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