Failure to Implement Care-Planned Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to implement fall-prevention interventions as outlined in a resident’s care plan. The resident was admitted and later re-admitted with diagnoses including a displaced intertrochanteric fracture of the left femur, hypotension, urinary incontinence, dizziness, difficulty walking, and muscle weakness. The resident’s fall risk care plan, addressing dizziness, impaired gait, muscle weakness, and psychoactive medication use, was initiated on 03/02/18 and revised on 10/21/25 to include specific interventions: bright colored paper as a visual aid to prompt the resident to ask for help and use the call light system, bright colored tape on wheelchair brake handles as visual reminders, and dycem on the wheelchair seat. On observation, surveyors and RN #204 noted that these care-planned interventions were not in place. There was no bright colored paper in the resident’s environment to cue use of the call light, no bright colored tape on the wheelchair brake handles, and no dycem on the wheelchair seat, despite these being listed in the fall care plan. RN #204 reported that the resident had experienced a fall with fracture the previous month and had received a new wheelchair, but staff had not applied the bright colored tape or dycem to the new wheelchair, and the signs in the room were not bright colored as specified in the plan of care. The resident’s daughter stated she believed the facility failed to implement preventive measures to prevent her mother’s fall that resulted in a fracture and reported that, despite her request, she had not yet received information about the fall and the care plan. Review of the facility’s Fall Policy and Procedures confirmed that the interdisciplinary team is required to develop and implement fall interventions based on assessed risk factors and to update the fall care plan in the electronic record.
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.