F0689

D

Failure to Maintain Call Bell Access and Fall Mats for High-Fall-Risk Resident

Rockville, Maryland Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to maintain a safe environment and provide adequate supervision to prevent accidents for a resident with a history of falls. The resident had been in the facility since November 2024 and had diagnoses including unspecified dementia, repeated falls, and multiple sclerosis. The resident’s care plan, initiated in November 2024 for actual falls and risk for falls related to generalized weakness and gait/balance problems, included interventions such as keeping commonly used items (call bell, TV remote, etc.) within easy reach and placing a fall mat at the bedside when the resident was in bed unattended, as tolerated. A prior unwitnessed fall on 7/11/25 had been documented, and the interdisciplinary team had decided to continue the existing plan of care.

On 1/12/26 at 10:12 AM, record review confirmed the care plan interventions, and at 11:26 AM the resident was observed lying in bed with the call bell cord hanging on the wall, out of reach. The overbed tray table, holding water, sandwiches, and the TV remote, was positioned by the window and also out of the resident’s reach, and there were no fall mats on the floor next to the bed. When questioned, the unit manager LPN located the call bell on the wall and placed it on the bed, and then moved the tray table within reach. A subsequent observation on 1/13/26 at 12:25 PM again found the call bell cord with attached call bell lying on the floor out of the resident’s reach and no fall mats at the bedside. These repeated observations demonstrated that staff did not consistently implement the resident’s care-planned fall prevention interventions regarding call bell accessibility and use of fall mats.