F0689

D

Failure to Implement Care-Planned Fall Prevention Interventions

Albany, Indiana Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to implement care-planned fall prevention interventions for a resident with multiple risk factors and a history of falls. The resident had diagnoses including age-related physical disability, syncope and collapse, difficulty walking, and vascular dementia, and was assessed as severely cognitively impaired and at high risk for falls on multiple fall risk assessments. Her care plan, initiated for fall risk related to impaired balance, included use of a bed alarm to remind staff she required assistance with bed mobility and transfers, placement of her bed against the wall per her preference, Dycem (non-slip material) in her recliner and wheelchair to prevent sliding, and use of a low bed with a floor mat to decrease injury risk when rolling out of bed. The Kardex also reflected these interventions.

Despite these documented interventions, observations on multiple occasions showed that the resident’s room setup and equipment did not match the care plan. On two separate dining room observations, the resident was seen in a wheelchair wearing nonskid socks and a brace on her right foot/leg, but when her room was observed, her bed was not against the wall, there was no non-slip mat in the recliner or wheelchair, and no fall mat was visible. Another observation found the resident lying in a low bed without a mat beside it, with the bed still not against the wall and no non-slip mats present in the wheelchair or recliner. These discrepancies occurred after the resident had experienced multiple documented falls, including falls on several dates, one of which resulted in a laceration with bleeding to her right eyebrow.

Staff interviews confirmed that the care-planned fall interventions were not being implemented as written. CNA staff stated that fall interventions were listed on the electronic Kardex and identified a bed alarm, increased supervision, and toileting assistance as the resident’s fall interventions, but acknowledged that the bed was not against the wall, there was no fall mat in use on the secured unit, and the non-slip mat was not present in the room, wheelchair, or recliner. The unit manager reported that fall mats were not utilized on the secured unit because they were considered a fall risk for wandering residents and that the resident’s care plan had not yet been revised after her move back to the secured unit. The DON similarly stated that the care plan should have been updated and that interventions such as the bed against the wall and non-slip mats in the wheelchair and recliner should have been in place, while also confirming that fall mats were not used on the secured unit due to being considered a trip hazard. The facility’s fall policy defined avoidable accidents as those occurring when the facility failed to implement interventions, including adequate supervision and assistive devices.