Failure to Individualize Fall Prevention Care Plans for Residents With Severe Cognitive Impairment
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement individualized, resident-centered fall prevention care plan interventions for two residents with severe cognitive impairment and dementia. One resident had a Brief Interview for Mental Status (BIMS) score of 5, diagnoses of dementia and reduced mobility, and experienced two unwitnessed falls, one in the hallway and one in her room. Despite these events and the resident’s confusion and inability to explain how the falls occurred, the care plan interventions implemented after the falls focused on encouraging the resident to ask for assistance with transfers and ambulation and ensuring the call light was within reach. The resident’s physician stated that the resident was not aware of her physical inabilities, had poor safety awareness, and had difficulty following commands, and the Assistant DON indicated that education and reliance on the call light were not appropriate interventions due to the resident’s impaired cognition and poor safety awareness. The second resident also had a BIMS score of 5, a diagnosis of dementia, and was dependent on staff for transfers, with a care plan identifying a self-care deficit and risk for falls related to dementia and confusion. The care plan directed staff to encourage the resident to use the call light for assistance. This resident had a witnessed fall in his room when he attempted to get into bed on his own after his wife told him to wait for help. Post-fall documentation noted confusion and disorientation, and the immediate action taken was to educate the resident on the importance of calling for staff assistance. Multiple staff, including an LPN, CNA, the Director of Social Services and Recreation, and the Assistant DON, as well as the resident’s physician, indicated that the resident would not understand or remember to use the call light due to poor cognition and progressed dementia, and the resident himself was unable to understand what a call light was used for. Despite this, the care plan interventions remained focused on education and call light use, which were not individualized to the residents’ cognitive limitations.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.