F0689

D

Failure to Implement Fall-Prevention Interventions and Ensure Call Light Access

Bellbrook, Ohio Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that fall-prevention interventions and call light access were consistently in place for a resident with a known history of falls and significant functional impairments. The resident, admitted with diagnoses including epilepsy, cerebral infarction, and hemiplegia/hemiparesis of the left non-dominant side, had a Minimum Data Set showing moderately impaired cognition and dependence on staff for toileting, bathing, and personal hygiene. The care plan, initiated due to fall risk related to impaired mobility, required bilateral fall mats on each side of the bed, the call light within reach at all times when in bed, education and reminders to use the call light before transfers and for toileting needs, personal items within reach, and a sign at eye level reminding the resident to use the call light. A prior fall investigation also identified bilateral fall mats as an intervention.

Despite these documented interventions and policies, multiple observations showed that the fall-prevention measures were not implemented as planned. On several occasions, the resident was observed lying in bed without fall mats on the floor, with the mat either leaning against the wall or present on only one side of the bed. At one point, the resident reported needing help with adult briefs while the call light was on the floor and not within reach, which was confirmed by a CNA. Subsequent observations continued to show inconsistent placement of fall mats, with only one mat on the right side or the mat again leaning against the wall instead of being on the floor beside the bed. These findings occurred in the context of facility policies requiring a resident-centered fall prevention plan and provision of a means for residents to call staff from bed and other locations.