F0689

D

Failure to Implement Fall-Prevention Interventions and Reassess Fall Risk After Multiple Falls

Springfield, Illinois Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions and accurate fall risk assessments for two residents with severe cognitive impairment and significant physical limitations. One resident was admitted with dysphasia, drug-induced Parkinsonism, and COPD, and her MDS documented severe cognitive impairment and dependence on staff for bed mobility and transfers, with several transfer items unable to be completed due to illness or injury. Her care plan identified her as at risk for falls and included interventions such as a body pillow while in bed and a fall mat next to the bed. Despite this, adverse event documentation showed she fell on two occasions, once after rolling over in bed due to improper positioning and once after sliding out of bed while trying to reach a bear that had fallen. At the time of surveyor observation, the body pillow intervention was not in place in her room, and the LPN assisting with her transfer acknowledged not knowing where the body pillow was or why it was not present.

The same resident’s fall risk assessments, completed on multiple dates, consistently documented her as a low fall risk and indicated she had not had any falls, even though she had documented falls on two separate dates. No fall risk assessments were completed following either of these falls, contrary to the care plan directive that fall risk assessments be completed on admission, quarterly, with significant changes, and with falls. The Administrator stated that any resident who had fallen in the last six months would not be considered a low fall risk and characterized the body pillow intervention added after one of the falls as new, although the tool had been previously listed. The DON stated she expected staff to follow fall interventions, and the facility’s Management of Falls policy required staff to identify and implement interventions based on resident-specific risks and causes.

A second resident, admitted with hemiplegia, heart failure, and muscle weakness, also had an MDS documenting severe cognitive impairment and a need for substantial/maximal assistance with bed mobility and all transfers. His care plan identified him as at risk for falls and included interventions such as side rails as enablers, reminders for safety awareness, locking brakes before transfers, non-skid socks, appropriate footwear, fall risk assessments on admission, quarterly, and with significant changes, placement where visible to staff, frequent checks beginning in the morning to see if he was ready to get out of bed, use of a body pillow for positioning, ensuring the call light and personal items were in reach, and toileting assistance every 1–2 hours. Adverse event documentation recorded multiple falls, including being lowered to the floor from the edge of his wheelchair, being found hanging out of bed with his knees on a floor mat, and being found on the floor with two skin tears, with contributing factors such as confusion/memory deficit, change in mental status, impaired communication, altered gait/balance, and improper/self-transfer. Despite these events, his fall risk assessment documented him as a low fall risk with no new evaluation completed. During observation, an LPN left him in bed wearing socks without grips and without a body pillow in place, while CNAs described his fall interventions as including a body pillow, fall mat, call light in reach, and frequent checks, and reported he was very unsteady, incontinent, and sometimes got up without using his call light.