F0655

D

Failure to Develop Baseline Fall-Prevention Care Plan for High-Risk New Admission

Kalamazoo, Michigan Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a baseline care plan addressing a resident’s high risk for falls within the required timeframe after admission. The resident was admitted with diagnoses including sepsis, weakness, cognitive deficit, insomnia, and a history of repeated falls. A BIMS score of 4 indicated severe cognitive impairment. A fall assessment completed shortly after admission identified the resident as high risk for falls with a score of 24, noting intermittent confusion, recent hospitalization, and wheelchair confinement with disorientation, although the mobility status documentation was not accurate. Despite these findings, no baseline care plan interventions were created to address fall risk, fall prevention, or the level of assistance needed for transfers and ambulation within the first days after admission.

The record showed that the only care plan initiated shortly after admission was an ADL care plan indicating the resident required assistance with daily care needs related to general weakness/debility and direct feeding assistance, with other ADL interventions not added until after the fall. There was no documentation in the care plan or record indicating whether the resident was continent or incontinent or whether a toileting program was in place. The fall prevention care plan and additional ADL interventions, including the resident’s transfer needs, were not developed until after the resident experienced a fall and was discharged to the hospital. The DON confirmed that the resident had been assessed as high risk for falls upon admission and that therapy had determined the resident required at least one-person assistance for transfers and ambulation, but this information was not entered into the care plan or Kardex until after the incident.

Staff interviews further demonstrated that direct care staff did not have clear guidance on the resident’s fall risk status or required assistance level. The RN manager stated that a baseline care plan had been developed within 24 hours of admission but did not include high fall risk, fall prevention interventions, or transfer/ambulation assistance needs, and acknowledged the importance of having transfer needs on the baseline care plan so staff know how to care for the resident. One CNA reported that the resident was able to get out of bed and walk but was unsteady and that she did not consider the resident a major fall risk because there were no fall-related signs or equipment in the room and no indication for frequent checks. Another CNA reported not knowing the resident’s continence status, that the resident could not communicate toileting needs, that the door remained closed all night, and that the last check occurred several hours before the fall. The DON stated that the care plan information should carry over to the Kardex for CNA use and acknowledged that the resident’s fall care plan and transfer status were missing until after the fall, which occurred four days after admission.