F0689

D

Failure to Follow Fall-Prevention Care Plans and Safe Transfer Practices

Mcpherson, Kansas Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a safe environment and follow fall-prevention care plans for two residents at high risk for falls. One resident (R9) had dementia without behavioral disturbance and Parkinson’s disease, with documented high fall risk and multiple prior falls. His care plan included multiple fall-prevention interventions, including a directive for the family to provide properly fitting shoes. Despite this, R9 continued to use shoes that were too big, and during an assisted walk with a gait belt and walker he tripped over his feet and fell, sustaining a laceration to the left eyebrow, a hematoma, and a skin tear to the left elbow, requiring emergency room evaluation and wound closure. The fall investigation specifically identified that his shoes were too big, and an administrative nurse acknowledged that the oversized shoes contributed to the fall and that staff should have followed the fall care plan intervention.

R9’s records also showed repeated falls in his room and from his recliner prior to the injury fall. On multiple occasions, staff heard a crash from his room and found him on the floor next to his recliner or air conditioner/heater unit after he attempted to get up or prepare his bed. Although his care plan directed staff to place the call light and personal items within reach, educate him to use the call light for assistance, offer a urinal every two hours, and encourage use of the dayroom for supervision when restless, he continued to experience falls in his room. One nurse’s note documented a fall from his recliner with staff then moving him to the dayroom for visualization, but the electronic medical record lacked a corresponding fall investigation for that event, despite facility policy requiring completion of a Fall Report and further investigation after any fall.

The second resident (R43) had dementia with severely impaired cognition, macular degeneration, repeated falls, and weakness, and was assessed as high risk for falls. Her care plan included use of a fall mat, staff education on proper sling placement, and a requirement for two staff with a sit-to-stand lift for transfers. She experienced two separate falls during sit-to-stand lift transfers to or from the toilet. In the first incident, her knees gave out and she slid out of the sling onto the bathroom floor. In the second incident, she let go of the lift, slid through the belt on the sling, and fell onto her bottom. In both cases, the fall investigations identified issues with the use of the sit-to-stand lift and sling, including that the sling was not put on correctly and that only one staff member was present during one of the falls, contrary to the care plan directive for two-person assistance. Staff interviewed later were unaware of these prior sit-to-stand falls and described her as a one-to-two-person transfer who could use the sit-to-stand lift if needed, indicating that the care plan directions and fall history were not consistently followed in practice.

Facility policies on Falls-Accident Reporting and the Resident Fall Checklist required that after any fall, licensed staff complete a Fall Report, perform a head-to-toe assessment before assisting the resident off the floor, notify the physician and responsible party, determine appropriate interventions to prevent further falls, update the care plan, obtain witness statements for falls with injury or possible injury, and document progress notes every shift for three days. The documented events for R9 and R43 show that falls occurred in the context of high fall risk, existing fall-prevention care plans, and specific policy requirements, yet the facility did not consistently implement the care-planned interventions (such as ensuring properly fitting shoes and two-person sit-to-stand transfers) or fully document and investigate all falls as required by its own policies.