F0657

D

Failure to Revise Fall Care Plans With Progressive Interventions After Multiple Resident Falls

Staunton, Illinois Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to revise and update fall care plans with progressive interventions for two residents after multiple falls, despite facility policy requiring immediate investigation and implementation of appropriate interventions following accidents and incidents. For one resident with systemic lupus erythematosus, epilepsy, altered mental status, and a BIMS score of 9, the care plan identified fall risk related to medications, tremors, and a history of falls with head injuries and a displaced dens fracture. The care plan listed several fall-prevention interventions such as keeping the bed in the lowest position, ensuring proper footwear, instructing the resident to avoid sudden position changes, orienting the resident to the room, providing adequate lighting, encouraging sitting on the side of the bed before standing, use of assistive devices, non-skid footwear and socks in bed, and Dycem in the wheelchair. However, after subsequent falls, no new or revised interventions were added to the care plan.

This resident experienced an unwitnessed fall on one occasion when a CNA found her on the floor at 7:15 AM. She reported that she had been washing her face and attempting to place a towel on the dresser when her wheelchair slid out from under her, causing her to hit the right side of her head, with blood noted on her hand, the floor, and the towel. Vital signs were documented, she was noted to be alert and oriented x2, and she was transferred to bed and then sent to the ED for further evaluation. The facility’s fall investigation documented that the fall occurred in the resident’s room while sitting, with the cause and root cause identified as the resident attempting to get out of the wheelchair. Despite this, there was no care plan intervention documented for this fall. Later, another fall occurred when the resident was observed leaning forward in the wheelchair and falling forward out of the chair, hitting her head on the leg of a sit-to-stand device. The fall investigation again identified the cause and root cause as the resident’s intent to get out of the wheelchair, with poor safety awareness and a BIMS score of 9, but again no new care plan interventions were documented.

The second resident involved had diagnoses including Parkinson’s disease, was on palliative/hospice care, had an indwelling catheter, and was dependent for several mobility tasks. His care plan identified fall risk related to psychotropic and opioid medications, Parkinson’s disease, involuntary movements, and a history of falls, including sliding out of bed. Interventions included keeping the bed in the lowest position, encouraging call light use, placing a floor mat at bedside, keeping the environment free of clutter, keeping personal belongings within reach, providing adequate lighting, adding a bolster on the mattress, and using a personal alarm. Despite these measures, the resident was later found on the bathroom floor on his right side during midnight rounding, with his indwelling catheter detached and a large amount of blood on the floor and penis. The fall investigation documented confusion, poor safety awareness, and attempts to get out of bed without assistance as the problem and root cause, but although it stated the care plan was updated, no specific new interventions were documented in the care plan.

On another occasion, this same resident was found lying on the floor mat next to the bed and window, on his stomach with arms at his side and legs extended, with a small red area to the left cheekbone and an indwelling catheter still patent. He was transferred back to bed via full mechanical lift and neuro checks were initiated. The fall investigation documented that the fall occurred in the resident’s room, with the resident found on the floor mat and no injuries noted. Again, no new or revised care plan interventions were documented following this fall. The DON later stated that some of the falls occurred before she was hired and that the care plan coordinator was new and learning. The facility’s Accidents & Incidents policy required the charge nurse to conduct an immediate investigation and implement appropriate interventions, and required the DON and IDT to review the incident, determine root cause, and implement appropriate interventions to attempt to prevent further falls, but the record review showed that progressive care plan interventions were not added after these falls for the two residents.