F0689

H

Failure to Provide Adequate Supervision and Effective Fall Prevention for High-Risk Residents

Atco, New Jersey Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and effective fall prevention for multiple cognitively impaired and high fall‑risk residents, and to thoroughly investigate and respond to falls. One resident with severe cognitive impairment, aphasia after stroke, repeated falls, bipolar disorder, muscle weakness, and a history of traumatic subdural hemorrhage was repeatedly placed in dayrooms without consistent staff supervision despite being identified as impulsive, at high risk for falls, and requiring supervised activities. Surveyors observed this resident multiple times in a wheelchair in the activity/dayroom areas, appearing restless, attempting to stand, and moving back and forth in the wheelchair while no staff were present in the room. The activity aide reported she was the only staff member assigned to cover two separate activity rooms, could not supervise both simultaneously, and that there were no staff physically assigned to monitor the activity area when she had to step out.

This same resident sustained at least 13 falls, including several unwitnessed falls in the resident’s room and multiple falls in the activity room and hallway. Documentation showed repeated nursing notes of the resident being found on the floor in the room, in doorways, and in the activity room, sometimes with skin tears or redness, and three falls resulted in injuries requiring emergency department evaluation: a contusion and laceration to the left supraorbital and frontal scalp after a hallway transfer incident where the CNA reported the resident’s legs became caught and the resident fell forward from the wheelchair; a large intramuscular hematoma of the right thigh after a fall in the activity room where the resident stood and missed the chair; and a closed head injury and facial laceration after another fall in the activity room with active bleeding from the forehead. Despite a care plan that specified the resident was impulsive, had poor safety awareness, required prompt response to requests for assistance, should be in common areas when out of bed, should not be left alone in the room in a wheelchair, and needed supervised activities to minimize falls, the facility did not ensure supervision in the dayrooms and did not consistently revise interventions after recurrent falls. Several fall investigations were missing entirely, and when interdisciplinary team notes were present, they often stated that all current interventions remained appropriate and that no additional interventions were needed, even after serious injuries and documentation that the resident required supervision in activities.

Another resident with Alzheimer’s disease, anxiety, diabetes, and a high fall‑risk score experienced multiple falls over a short period, including several falls with no injury and one fall with skin tears to the left hand and elbow. The care plan listed general fall‑prevention interventions such as reviewing past falls, attempting to determine causes, anticipating needs, ensuring call light access, prompt response to assistance requests, appropriate footwear, maintaining the bed in the lowest position, toileting schedules, therapy evaluations, and activities to promote exercise and diversion. However, for at least one documented fall, no new interventions were added, and facility accident/incident reports lacked key information such as when the resident was last seen or toileted, footwear at the time of the incident, bed position, or whether the resident had participated in activities as care‑planned. Effectiveness of interventions and root causes of falls were not clearly evaluated or documented, contrary to the facility’s own falls policies that required identification of precipitating factors, cause identification within 24 hours, and ongoing adjustment of interventions until falls were reduced.

A third resident with severe cognitive impairment, hemiplegia and hemiparesis following cerebral infarction, and epilepsy had a documented fall during in‑bed repositioning. A risk management report described that while a CNA was turning the resident onto the right side, the resident’s leg hit the floor while the body remained on the bed. The interdisciplinary team later discussed this event and identified the need for staff to position the resident in the center of the bed before turning to one side or the other. However, the resident’s comprehensive care plan for falls was not updated to include this fall or the specific intervention related to proper positioning prior to turning. Overall, across these residents, the facility’s fall‑related policies did not address supervision, multiple falls were not thoroughly investigated, causal factors were often not identified, and care plans were not consistently updated with new or specific interventions in response to recurrent falls and injuries.

The facility’s written policies on managing falls and fall risk, the falls clinical protocol, and the falls risk assessment policy required staff to identify interventions related to specific risks and causes, implement resident‑centered fall prevention plans, monitor and document responses to interventions, and re‑evaluate and modify interventions when falls continued. These policies also required staff to evaluate when and where falls occurred, document precipitating factors, and attempt to define possible causes within 24 hours, with physician involvement when causes were unclear or falls persisted. Despite these requirements, the policies did not address supervision as part of fall management, and in practice, the facility did not ensure adequate supervision in activity areas, did not consistently complete or document fall investigations, and did not reliably implement or update individualized interventions after falls for the residents reviewed.