F0689

D

Failure to Implement and Maintain Appropriate Fall Interventions for High-Risk Resident

Solon, Ohio Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and consistently maintain appropriate fall interventions for a resident with severe cognitive and physical impairments and a known high risk for falls. The resident was admitted with anoxic brain damage, intracranial injury, post-traumatic seizures, and spastic quadriplegic cerebral palsy, and was wheelchair-bound with weakness in all extremities. An MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment, and documented that the resident was dependent on staff for ADLs and had poor safety awareness. The care plan identified increased fall risk and an actual fall related to brain injury, with interventions such as ensuring a safe environment, anticipating needs, keeping the call light within reach, using handrails, and keeping the bed in the lowest position at night. Hospital admission paperwork and fall risk assessments identified the resident as a high fall risk who required a bed alarm and had a history of falls.

On one occasion, the resident experienced an unwitnessed fall around 12:30 A.M., when an RN heard a sound and found the resident with his head down on the right side of the bed and legs still in bed. The resident was repositioned and placed back on the ventilator, and shortly afterward had projectile vomiting and was sent to the hospital due to his history of intracranial surgery and presenting symptoms. Hospital documentation diagnosed a fall with head injury and again identified the resident as high risk for falling. A post-fall investigation noted contributing factors including poor bed mobility, decreased safety, epilepsy, history of seizure activity, loss of trunk control, impaired posture stability, decreased safety awareness, and sliding out of bed with inability to self-correct or recognize the need for assistance. The investigation document referenced prior interventions and current interventions such as repositioning, neurological checks, and use of an extended bed and extended air mattress, but did not show prior or subsequent implementation of floor mats.

Subsequent observations by surveyors on multiple occasions showed the resident in bed without fall mats in place, despite his inability to voluntarily control his body and only being able to follow with his eyes and slightly move his head. Staff interviews confirmed that the resident was fully dependent for ADLs, was a fall risk, and required checks every two hours, but that floor mats were not used as a fall intervention. A CNA reported that the resident used a special high-back wheelchair to decrease fall risk when out of bed, that the bed was kept in the highest position during the day, and that she had never seen it in the lowest position. The DON acknowledged that the resident was identified as a fall risk based on his diagnoses and that there were no fall mats in place prior to the fall, and stated that she did not implement floor mats because she felt they were not needed based on her assessment. The facility’s fall management policy required staff to identify interventions related to specific risks and causes and to monitor and document residents’ responses to interventions intended to reduce falls or fall risk, but the resident’s identified risks and documented fall history were not consistently addressed with appropriate and sustained fall interventions.