F0689

G

Failure to Implement Effective Fall Management and Care Planning for High-Risk Residents

Minneapolis, Minnesota Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement an effective fall management program, including accurate assessment, care planning, and follow-through on fall-related interventions for multiple residents at high risk for falls. For one resident with hemiplegia, epilepsy, Charcot foot, dizziness, severe cognitive impairment, and dependence in most ADLs, the record showed repeated unwitnessed falls associated with dizziness and self-transfers. Although the care plan labeled the resident as high risk for falls and listed various interventions such as low bed, therapy screens, anti-skid tape, and medication review, the facility did not complete ordered orthostatic blood pressures after falls, did not revise the care plan to address ongoing dizziness and self-transfers, and did not conduct a comprehensive assessment of the cause of the dizziness. Post-fall reviews repeatedly identified dizziness and self-transfers as root causes, but there was no evidence of a thorough root cause analysis or effective modification of interventions, and the resident’s environment lacked consistent no-skid surfaces near the bed despite independent transfers.

Another resident with Parkinson’s disease, CHF, atrial flutter, diabetes, dizziness, and dyskinetic movements was identified as a moderate fall risk on a Morse Fall Scale at admission and had a PT evaluation noting unsteadiness and fear of falling. However, no fall prevention care plan was initiated after admission despite the identified risk. The resident experienced an unwitnessed fall while attempting to walk to the bathroom unassisted, after which she was found on the floor with pain in multiple areas and later diagnosed in the ED with an acute T12 compression fracture requiring hospitalization. The facility’s records showed that the baseline care plan, including fall interventions, was not initiated until after the resident had already been transferred to the hospital and did not return. Interviews with staff and the ADON confirmed that the baseline care plan had not been completed over the weekend, that there was no investigation into the fall because the resident did not return, and that the absence of a care plan increased the resident’s risk of falls.

A third resident with stroke, diabetes, visual impairment, epilepsy, hemiplegia, and foot drop was assessed as high risk for falls and required substantial assistance with transfers and ADLs. The fall care plan initially identified the resident as a moderate fall risk and included general interventions such as medication review, pain evaluation, snacks, therapy, and clutter-free environment, but did not address specific, evolving fall patterns. Over a series of unwitnessed falls, the resident repeatedly attempted self-transfers, tried to retrieve a fallen call light, ambulated without assistance, and fell while trying to put on shoes. Incident reports frequently left predisposing environmental and physiological factors blank, and post-fall reviews documented root causes such as new admission, self-transfers, and balance issues but lacked comprehensive causal analysis. Care plan revisions were delayed or incomplete, with some interventions (e.g., wheelchair placement by bed, gripper socks, removal of shoes as visual cues) added days to weeks after falls, and staff interviews revealed unawareness of key fall-prevention interventions such as wheelchair placement and specific monitoring expectations.

Across these residents, the facility did not consistently ensure that staff knew residents’ transfer status or fall interventions, as multiple NAs and LPNs reported needing to check the EHR or being unable to articulate current fall-prevention measures. One nurse aide caring for the resident with hemiplegia and dizziness was unaware of the resident’s transfer status and falls until checking the Kardex, which showed a total mechanical lift order that was not being followed, while the resident was observed independently transferring without no-skid tape at the bedside. Another LPN caring for the same resident acknowledged daily reports of dizziness but could not identify any fall-prevention interventions in place. For the resident with Parkinson’s disease, the LPN who found her on the floor could not describe how the resident was supposed to transfer or what fall interventions should have been used. These documented inactions and gaps in assessment, care planning, and staff awareness contributed to multiple unwitnessed falls, including two residents who sustained major injuries (a tibial plateau fracture and a spinal fracture) requiring hospitalization.

The facility’s fall incident documentation and IDT post-fall reviews repeatedly lacked complete information on environmental, physiological, and situational predisposing factors, and often recorded generic immediate actions such as encouragement to call for help, without detailed analysis of why residents continued to self-transfer or how dizziness, balance, cognition, and environmental setup contributed to the falls. Orders and recommendations for orthostatic blood pressure monitoring for the dizzy resident were not carried out or documented, and there was no evidence that the results were evaluated or used to adjust care. Residents reported not being involved in care plan development or being asked about symptoms such as dizziness, and one resident’s family member reported that a requested fall mat was never provided. Collectively, these actions and omissions demonstrate that the facility failed to maintain an environment free from accident hazards and did not provide adequate supervision and individualized fall-prevention interventions for residents at known risk for falls.