F0689

D

Failure to Provide Adequate Supervision for Cognitively Impaired Resident With Recurrent Falls

Marion, Indiana Survey Completed on 01-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and prevent repeated falls for a severely cognitively impaired resident. The resident had diagnoses including dementia, major depressive disorder, bradycardia, and atrial fibrillation, and required partial to maximal staff assistance with transfers, ambulation, toileting, and hygiene. MDS assessments documented severe cognitive impairment, disorganized thinking, inattention, poor safety awareness, frequent incontinence, and shortness of breath with exertion. Over time, the resident experienced multiple falls, including falls with injuries and a major injury, despite being identified as at risk for falls related to impaired judgment, memory loss, history of falls, narcotic analgesics, and psychotropic medications.

From late December through mid-January, the resident had a series of falls in her room, bathroom, and common areas, often while attempting to transfer or ambulate without assistance. She was repeatedly found on the floor beside her bed, in the bathroom, near her recliner, or in doorways, frequently after attempting self-transfers or ambulating alone. Documentation consistently identified root causes such as transferring or ambulating without assistance, losing balance, and sliding from bed, with contributing factors of dementia, severe cognitive impairment, poor safety awareness, and a history of multiple recent falls. The record also notes that the resident sometimes removed her shoes, wore only socks, or manipulated and removed chair alarms, and that she frequently refused to use her wheelchair when going to the bathroom.

Despite the resident’s ongoing pattern of falls and her severe cognitive impairment, the facility’s approach relied heavily on intermittent checks, signage, and environmental measures while the resident continued to self-transfer and ambulate unassisted. Staff and leadership interviews acknowledged that the resident had fallen many times in a short period, that some falls were attributed to maladaptive behaviors and possibly bradycardia, and that she continued to try to care for herself and get up on her own. Staff reported trying to keep her in common areas when awake and to keep her room door open to observe her, but observations showed that at times the resident was in bed with the door closed. The cumulative documentation shows repeated falls, including a minimally displaced radial head fracture of the right elbow, occurring in the context of severe cognitive impairment and ongoing self-initiated transfers and ambulation without consistent, effective supervision to prevent these accidents.

The care plan identified the resident as at risk for falls and referenced her fracture from a fall, with interventions such as scheduled toileting, use of an anti-roll back device on the wheelchair, encouraging her to stay in common areas while up, non-slip footwear, and assisting her to areas of increased supervision when restless. However, the clinical record and narrative notes describe continued falls under similar circumstances—unassisted transfers, ambulation without help, and attempts to reach the bathroom or bed independently—indicating that the resident’s needs for supervision were not effectively met. Interviews with CNAs and nursing leadership further confirm that, despite awareness of her frequent falls and behaviors, the resident was still often in situations where she could and did attempt to move without assistance, leading to repeated accidents.

Throughout this period, the resident’s pattern of behavior, cognitive status, and physical limitations remained consistent, and the facility’s own fall investigations repeatedly cited the same root causes and contributing factors. The facility’s policy states that it will provide an environment free from accident hazards and implement supervision and assistive devices consistent with residents’ needs to prevent avoidable accidents. In this case, the documented series of falls, including those resulting in injury and a major injury, occurred while the resident continued to self-transfer and ambulate without adequate, effective supervision, constituting the failure cited in the deficiency.