Failure to Implement Effective Fall-Prevention Measures for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents for a resident with a known high fall risk. The facility’s own Accidents/Incidents Reporting policy required implementation, monitoring, and modification of interventions to reduce hazards and risks, including the use of position change alarms such as chair and bed sensor pads, floor mats, and motion detectors. Despite this, documentation showed that the resident, who had a history of two or more prior falls and a high fall risk score of 16, did not have any position change alarms or other documented safety measures in place to prevent falls when attempting to stand or walk unsupervised. The resident had severe cognitive impairment, dementia, bipolar disorder, impaired lower extremity function requiring a wheelchair, and was dependent or required moderate assistance for bed mobility, transfers, and toileting. A behavior care plan noted the resident’s potential to attempt unsafe maneuvers such as standing and trying to walk without supervision, with poor cognition, poor safety awareness, and poor impulse control. The fall risk care plans identified the resident as high risk for falls related to confusion and gait/balance problems and, in one version, listed use of chair/bed alarms as an intervention; however, there was no documented evidence that such alarms or other assistive devices were actually in place for this resident. On the date of the incident, the resident was found sitting on the floor in the hallway with their wheelchair on its side after an unwitnessed fall, having attempted to stand and lost balance. The resident complained of back pain, and subsequent imaging showed osteopenia and a T12 vertebral body compression fracture of undetermined age. Staff interviews indicated that the resident did not have an alarm on their wheelchair or other safety devices during their stay, although a CNA recalled bedside floor mats and reported that the resident was typically seated outside their room near the nurse’s station and would edge toward the edge of the wheelchair and end up on the floor. The DON and Administrator acknowledged that the resident was a frequent faller and was on close supervision/monitoring, but there remained no documentation of specific assistive devices or effective fall-prevention measures in place at the time of the fall.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.