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F0689
G

Failure to Prevent Accidents and Implement Effective Fall Interventions

Watertown, Wisconsin Survey Completed on 04-10-2025

Penalty

Fine: $40,48015 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that two residents received adequate supervision and assistance devices to prevent accidents, resulting in one resident experiencing actual harm. One resident, who had multiple diagnoses including stroke, muscle weakness, and moderate cognitive impairment, was assessed as a moderate fall risk and required two staff for transfers with a Hoyer lift, as well as specific interventions such as keeping the bed against the wall and the call light within reach. Despite these documented interventions, the resident experienced a fall with major injury when a CNA attempted to reposition the resident alone, rolling the resident away from himself, which led to the resident falling to the floor and sustaining a right hip fracture. At the time of surveyor observation, the resident's bed was not against the wall and the call light was on the ground, not within reach, contrary to the care plan requirements. Another resident with diagnoses including dementia and a history of falls experienced twelve falls over a period of time. The care plan included standard fall prevention interventions such as offering toileting every two hours, ensuring the call light was within reach, and not leaving the resident unattended while awake. However, after each fall, the facility either failed to add new interventions to the care plan or only added interventions that were already considered standard practice, such as offering toileting at certain times. The facility did not complete a root cause analysis for any of the falls, including those resulting in injury, and did not implement individualized or effective interventions to address the repeated falls. Interviews with the DON confirmed that root cause analyses were not performed unless there was an injury, and that interventions added after falls were often not new or specific to the resident's needs. The interdisciplinary team reviewed falls in morning meetings, but did not identify or address the lack of new interventions for the resident with repeated falls. The facility's failure to follow care plans, ensure required safety devices were in place, and implement appropriate interventions after falls led to continued risk and actual harm for the residents involved.

See complete original report
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