F0689

G

Failure to Consistently Implement Fall-Prevention Interventions for a High Fall-Risk Resident

Lakewood, Colorado Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to maintain a resident environment free from accident hazards and to provide adequate supervision and consistent implementation of fall-prevention interventions for one high fall-risk resident. The facility’s own Falls and Fall Risk, Managing Policy required staff to identify and implement resident-specific interventions, adjust them if falls recurred, and monitor/document responses. Resident #10, an individual over age 65 with emphysema, dementia, paranoid personality disorder, epilepsy, and a history of repeated falls, was assessed as having moderate cognitive impairment and needing staff supervision for toileting, dressing, and ambulation. The comprehensive care plan, initiated and updated over several months, identified the resident as at risk for falls with and without injury and listed multiple interventions, including call light and personal items within reach, traction strips and reminder signs, bed in low position, room relocation closer to the nurses’ station, hipsters, a low-profile fall mat, and offering a scrum cap when out of bed.

Despite these identified risks and planned interventions, the resident sustained eight falls within a three‑month period, including several unwitnessed or unexplained falls and a significant fall resulting in a closed head injury. Documentation showed falls on multiple dates, including events where the resident was found on the floor near his wheelchair, bed, or in the bathroom, and one witnessed fall when he turned too fast and lost balance. On one occasion, a nurse documented being informed after the fact that the resident had fallen on a previous shift without a corresponding report or injury documentation at the time of the event. Emergency room records from one fall documented a closed head injury with periorbital and parietal scalp hematomas, and a later physician note referenced MRI findings of a subdural hematoma, while the facility reported the resident remained neurologically stable.

During on-site observations, surveyors found that key fall-prevention interventions were not consistently in place for this resident. On multiple occasions, the resident was observed lying in bed in a different bed position (bed A) than his assigned bed (bed B) without a fall mat in place and without the call light within reach, contrary to the care plan and physician orders. The resident’s bathroom lacked traction strips despite this being a listed intervention. Staff interviews revealed inconsistent awareness and implementation of fall precautions: one CNA stated the resident was not a fall risk and was unaware of his fall history, could not locate his hipsters, and believed the bed did not need to be low. An LPN, who acknowledged the resident was a high fall risk, confirmed that the fall mat was placed by the wrong bed side and that the resident’s hipsters and scrum cap, along with other personal belongings, remained in the resident’s old room more than a week after a permanent room move. The DON confirmed that fall interventions should be used at all times and that staff were expected to use the care plan, Kardex, and intervention binders to guide resident safety, but the resident’s interventions and belongings had not been properly transferred or consistently applied.