F0689

D

Failure to Implement Ordered Fall-Prevention Interventions After Repeated Bed Falls

Bloomfield Hills, Michigan Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain fall-prevention interventions for a resident with dementia, osteoporosis, essential hypertension, moderately impaired cognition, and total incontinence. The resident required substantial/maximal assistance for bed mobility and transfers and had experienced a decline in ADL function, needing 1–2 person assistance with dressing, ambulating, and toileting. Progress notes documented two unwitnessed falls from bed on consecutive days, with the resident found on the floor near the bed on both occasions and unable to describe the events. The falls care plan, initiated earlier, identified the resident as at risk for falls due to decreased mobility, cognitive impairment, incontinence, and medication side effects.

Despite this identified risk and the documented falls, required interventions were not in place at the time of surveyor observations. The care plan and IDT documentation called for bolsters or an overlay barrier to the mattress and a non-skid mat to the right side of the bed. However, on multiple observations, the resident was found lying on a regular mattress without bolsters or mattress overlay applied to the bed, and no non-skid mat was present on the floor. The mattress overlay was instead observed in the resident’s wheelchair. When interviewed, the assigned LPN did not know what the mattress overlay was or that it should be on the bed, and the unit manager initially stated the overlay was in place before acknowledging it was not. The DON stated interventions would not be documented until in place, despite the care plan and IDT notes already reflecting these interventions, and did not provide an explanation for their absence at the bedside.