Failure to Care Plan and Implement Interventions for High Fall-Risk Resident After Fall
Penalty
Summary
The deficiency involves the facility’s failure to assess and care plan for a resident identified as high risk for falls, and to implement post-fall interventions after an actual fall. The resident was admitted with osteomyelitis of the left ankle and foot, peripheral vascular disease, and hypertension, and was assessed on 02/16/26 as being at high risk for falls. On 03/01/26 at 4:30 p.m., nursing notes documented that the resident rolled out of bed while reaching for a phone charger, landing on the right side of the body between the bed and a recliner, and sustaining a gash to the right temple with swelling and headache, requiring transfer to the emergency room. Later that evening, notes indicated the resident returned from the hospital with sutures to the forehead, a negative CT scan, and that safety checks were in place with the bed in a low position and instructions given to report dizziness or lightheadedness. Despite the high fall risk assessment and the documented fall with head injury, review of the medical record from 03/01/26 through 03/10/26 showed no care plan addressing the resident’s fall risk or the actual fall. The comprehensive MDS dated 03/03/26 documented the resident as cognitively intact, able to make self-understood, and at risk for falls with no history of falls, even though a fall had occurred on 03/01/26. Observation on 03/10/26 found the resident in a low bed with the call light on the floor and not within reach, and the resident reported having been unable to find the call light at the time of the fall and lying on the floor for a long time before help arrived. Interviews with the ADON, MDS coordinator, interim DON, and Administrator confirmed that the fall was not correctly entered into the EMR, which prevented triggering of post-fall assessments and documentation, and that no fall care plan or interventions had been developed for this resident despite facility policy requiring assessment and care planning for residents at risk for falls and after every fall.
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