F0656

D

Failure to Timely Revise Fall-Prevention Care Plan After Multiple Falls

Westland, Michigan Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely implement and revise fall-prevention care plan interventions following multiple falls for one resident. The resident was admitted with muscle wasting and atrophy, had a BIMS score of 5/15 indicating impaired cognition, and required staff assistance with bed mobility and transfers. On one observation, the resident was seen lying in bed with their feet hanging off the side, the bed not in a low position, and a blanket and sling pad underneath them, shortly after returning from the hospital following a fall in which they hit their head while on a blood thinner. Incident reports documented that on one date the resident was found on their right side on the floor in front of their wheelchair before bedtime, with range of motion performed and no apparent injuries noted.

A subsequent incident report documented that on another date the resident, described as alert and oriented x1, was observed on the floor with their head down, with an abrasion to the right side of the face, old bruises to the left ring finger and right thigh, increased confusion, inability to follow simple directions, and episodes of throwing themself to the floor and to the side of the bed several times with difficulty redirecting. The resident was also documented as receiving Eliquis 5 mg twice daily. Review of the fall care plan showed no new fall-prevention interventions were added after these falls and after the resident’s readmission to the facility. Staff interviews confirmed that timely interventions should be implemented by the floor nurse after a fall, and facility policy stated that the licensed nurse will review and/or revise the care plan and link it to the resident Kardex, but this was not done for this resident following the documented falls.