F0656

D

Failure to Implement Care-Planned Fall Prevention Devices for High-Risk Residents

Bastrop, Louisiana Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement person-centered care plan interventions for two residents identified as high fall risks. One resident with dementia, Alzheimer’s disease, muscle weakness, lack of coordination, and moderate cognitive impairment used a manual wheelchair and required assistance with ADLs. The resident’s care plan, updated after a fall, specified that therapy would screen the resident and that a stand-alone motion sensor would be placed in the bathroom to notify staff when the resident entered. During an observation, the resident was seated in a wheelchair in the room while the bathroom motion sensor was found lying on the floor and not alarming when someone walked in front of it. A subsequent observation with an LPN confirmed the motion sensor in the bathroom was not turned on while the resident was in the room.

The second resident had hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes, atherosclerotic heart disease, bipolar disorder, hyperlipidemia, and anemia, and used a manual wheelchair for mobility. This resident’s fall risk assessments identified a high risk for falls, and the care plan documented risk factors including weakness, history of falls, cognitive impairment, polypharmacy, psychotropic medication use, lack of safety awareness, and loss of mobility with hemiplegia. An approach added to the care plan after a fall required wheelchair brake extenders to be placed on the wheelchair. During observations in the main dining area, the resident was seen seated upright in the wheelchair without brake extenders in place, and both an LPN and the DON confirmed that the wheelchair brake extenders were not present as required by the care plan.