F0689

D

Failure to Implement and Update Individualized Fall and Transfer Safety Measures

Aurora, Ohio Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, effective, and individualized fall management program for a resident identified as high risk for falls. The resident was admitted with diagnoses including chronic venous insufficiency, osteoarthritis, dementia, muscle weakness, and a healing pubic fracture. A fall risk assessment identified the resident as high risk, and the care plan noted impaired safety awareness and deterioration in ADLs related to chronic venous stasis. Interventions included encouraging non-skid socks as tolerated and, later, providing two-person assistance for transfers and use of a manual wheelchair with one-person assist for mobility. The admission and subsequent MDS assessments documented severely impaired cognition and dependence or substantial/maximal assistance needs for transfers, toileting, and bed mobility.

Despite these identified risks and documented needs, the facility did not update or consistently implement the resident’s fall and safety care plan in line with current functional status and therapy recommendations. A PT discharge summary indicated the resident generally required minimal assistance for functional tasks and safety cueing, and recommended limited assistance for safety due to high fall risk and cognitive deficits. However, no changes were made to the fall/safety plan of care after therapy discharge. Later MDS assessments continued to show the resident as dependent for transfers, but the care plan was not revised to reconcile these findings with therapy recommendations, and the DON confirmed the care plan had not been updated following PT discharge.

On one night, the resident experienced an unwitnessed fall in her room. She was last seen in bed and later found on the floor, sitting on her buttocks, barefoot, with a left elbow skin tear. The fall investigation documented that all fall interventions were in place, yet also noted the resident was barefoot, without explaining why non-skid socks, which were a care-planned intervention, were not in use. No witness statement was obtained from the CNA assigned to the resident that shift, and the root cause analysis attributed the fall to the resident being old, confused, and unbalanced, without addressing the missing non-skid socks or other specific environmental or supervision factors.

Later that same day, the resident sustained a severe skin tear during a transfer from wheelchair to bed. An incident investigation and CNA statement revealed that a CNA, working alone, transferred the resident and the resident’s leg scraped against the wheelchair leg rest, causing immediate and significant bleeding. The resident was on warfarin and required hospital evaluation, where she was diagnosed with a closed nondisplaced pelvic fracture and multiple skin tears. The DON confirmed that the care plan in place required two-person assistance for transfers, but only one CNA performed the transfer. The incident investigation for the skin tear did not include a root cause analysis. Interviews also showed inconsistencies in staff recall and documentation, including the assigned CNA not recalling the fall and the absence of timely, complete witness statements. These actions and omissions demonstrate the facility’s failure to implement and individualize fall and accident prevention measures as required by the resident’s assessed needs and care plan.

Additional documentation and interviews highlighted further discrepancies between assessed needs, care plan directives, and actual care provided. The DON and MDS nurse confirmed that MDS data indicated the resident was dependent for transfers, which the MDS nurse equated with a two-person assist, while therapy had recommended minimal assistance with safety cueing. The care plan was not updated to reflect or reconcile these differing assessments, and the CNA who performed the transfer alone stated she believed she could transfer the resident by herself due to the resident’s weight, without referencing the care plan requirements. The facility’s fall prevention and management policy required assessment of fall risks, implementation of preventive measures, and review and investigation of all falls, but the investigations for both the fall and the transfer-related injury lacked complete root cause analyses and did not fully address why care-planned interventions, such as non-skid socks and two-person transfers, were not followed.