F0689

G

Failure to Analyze Recurrent Falls and Implement Adequate Supervision and Environmental Controls

Laplata, Maryland Survey Completed on 01-09-2026

Penalty

Fine: $17,215

Summary

Facility staff failed to identify and evaluate factors contributing to a resident’s recurrent falls and did not ensure appropriate interventions were implemented to prevent future occurrences. The resident had dementia with severe cognitive impairment, poor gait and balance, poor safety comprehension, incontinence, and a history of falls, and was assessed as high risk for falls. A fall care plan initiated months earlier included environmental decluttering, adequate lighting, appropriate footwear, and fall mats, with a goal to keep the resident free of falls. After a right hip fracture from a fall, the care plan called for a toileting program and for each fall to be reviewed for root cause and for the cause to be removed. However, the care plan did not include any intervention specifying the level of supervision needed to prevent falls.

Multiple subsequent falls were documented on Change in Condition (CIC) forms, but these events were not consistently incorporated into the care plan, and new interventions were often not added. Falls on 6/16/25 and 7/1/25 were not listed on the care plan, no new interventions were implemented, and there was no evidence that staff reviewed these falls to determine their causes, despite the care plan directive to do so. A toileting program ordered to prevent falls was not implemented, as confirmed by review of the physician’s orders, MAR, and TAR, and by interview with an LPN who stated the resident was not on a toileting program. A later fall on 12/23/25 was added to the care plan, but only one new intervention (ensuring the bed was locked and in low position) was documented, again with no evidence of a fall review or root cause analysis.

On 12/31/25, the resident sustained another fall, was found on the floor near the bathroom doorway while staff were passing lunch trays and administering medications, and was subsequently diagnosed with a left hip fracture requiring surgical intervention. After readmission, the fall care plan was updated with only one intervention to place the wheelchair beside the bed, an action staff had already been performing per LPN interview, and there was still no documented review of the fall for root cause or any intervention addressing the level of supervision needed. Observation of the resident’s new room showed additional unaddressed hazards: the bed was too high, there were no fall mats, the wheelchair was not beside the bed and there was no space to place it there, the curtain was closed preventing staff from seeing the resident, the room was far from the nurses’ station, and the roommate’s side was cluttered with low lighting and items protruding into the walkway. These conditions, combined with the resident’s impulsivity, poor safety awareness, and frequent attempts to get up unassisted, reflected the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent accidents.