F0689

D

Failure to Implement Progressive Fall-Prevention Interventions After Repeated Resident Falls

Staunton, Illinois Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide progressive fall-prevention interventions for two residents with known fall risks and repeated falls. For one resident with systemic lupus erythematosus, epilepsy, altered mental status, a BIMS score of 9/15, and a need for substantial/maximal assistance with bed mobility and transfers, 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 general 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, reinforcing sitting on the side of the bed before standing, and use of assistive devices, as well as non-skid footwear and Dycem in the wheelchair. However, after subsequent falls, no new or revised care plan interventions were documented.

This same resident experienced an unwitnessed fall from the wheelchair in the resident room while washing her face and reaching to place a towel on the dresser, during which the wheelchair reportedly slid out from under her and she hit the right side of her head, with blood noted on her hand, the floor, and the towel. The facility’s fall investigation documented that the fall occurred while the resident was sitting, that it was related to patient intent or behavior, and that the resident had just gotten out of bed and was sitting in the wheelchair. The problem statement and root cause both identified the resident’s attempt to get out of the wheelchair, but there is no documentation of any new care plan interventions being added in response to this fall. Later, the resident had another fall when she leaned forward in the wheelchair and fell forward out of the chair, hitting her head on the leg of a sit-to-stand device. The investigation again attributed the fall to patient intent or behavior, poor safety awareness, and the resident’s intention to get out of the wheelchair to get to bed, yet again no care plan interventions were documented for this fall.

A second resident, with Parkinson’s disease, palliative care, malignant neoplasm of the renal pelvis, a BIMS score of 12/15, dependence for multiple mobility tasks, and an indwelling catheter, was also care planned as being at risk for falls due to psychotropic and opioid medications, Parkinson’s disease, involuntary movements, and a history of falls. The care plan noted that the resident had a low bed, double mattresses, a floor mat at bedside, and later a bolster on the mattress and a personal alarm. Despite these measures, the resident was found on the bathroom floor at night with the indwelling catheter detached and a large amount of blood on the floor and penis, and the fall investigation identified confusion, poor safety awareness, and attempts to get out of bed without assistance as the problem and root cause. Although the investigation form stated that the care plan was updated, there is no specific care plan intervention documented for this fall. The same resident was later found lying on the floor mat next to the bed and window, on his stomach with slow responsiveness and a small red area on the left cheekbone, and again no new care plan intervention was documented for 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, while the facility’s accidents and incidents policy requires immediate investigation and implementation of appropriate interventions, with IDT review to determine root cause and implement appropriate interventions to attempt to prevent further falls.