F0689

E

Failure to Follow Fall Management Protocol for High-Risk Residents

Gig Harbor, Washington Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents, specifically by not following its own fall management protocol. The facility’s policy required completion of fall risk assessments on admission, readmission, quarterly, with changes in condition, and after any fall, and referenced Lippincott procedures that directed staff to keep beds in the lowest position and call lights within reach. Surveyors found multiple instances where residents identified as high fall risk had beds left in a high (waist-level) position and call lights not within reach, and one resident had an outdated fall risk assessment. Staff interviews confirmed that the expectation was for high fall risk residents to have beds in low position and call lights within reach, and that these practices were considered standard of care.

One resident with a history of subdural and subarachnoid hemorrhage, prior falls, muscle weakness, difficulty walking, and restlessness/agitation was admitted to the facility, assessed with a high fall risk score of 20, and care planned for bed in lowest position, use of a mechanical lift, appropriate footwear, and PT evaluation. Progress notes documented that this resident arrived confused and, later that same day, was found on the floor next to the bed with their head against the wall and legs tangled in bed sheets, experiencing seizure activity after a fall from bed. The risk management document noted the bed was in low position and the resident was agitated and confused, and the resident was sent back to the hospital for evaluation and treatment.

Another resident with altered mental status, muscle weakness, repeated falls, and spinal stenosis had multiple documented falls, including rolling out of bed and being found on a floor mat with fecal matter on their face and floor. This resident had a high fall risk score of 20 and was care planned for call light within reach and other fall interventions, including bilateral mobility rails and floor mats. However, observation showed the bed placed against the wall with the call light hanging down behind the bed and not within reach, despite the resident being on the facility’s falling star protocol as indicated by a star on the door.

A resident with cognitive impairment, muscle weakness, repeated falls, and unsteadiness on feet had multiple documented falls while attempting to use a urinal independently, exercising, and sliding from a chair in the dining room. This resident had a high fall risk score of 24 and a care plan requiring the call light and a reacher to be within reach. Observations on two separate days showed the resident sitting in a wheelchair next to a bed placed against the wall, with the call light hanging behind the bed and no reacher within reach, despite a falling star indicator on the door. The resident reported being unable to reach the call light and not knowing where the reacher was.

Additional residents with diagnoses including adult failure to thrive, vascular dementia, muscle weakness, difficulty walking, hemiplegia/hemiparesis, repeated falls, unsteadiness on feet, chronic pain, epilepsy, and severe cognitive impairment were all assessed as high fall risk with fall risk scores ranging from 12 to 16. For several of these residents, surveyors observed beds in a high, waist-level position while the residents were in bed. Cognitively intact residents reported that staff left their beds at that height after providing care and one resident stated they feared falling while in bed and preferred the bed to be lower. For one severely cognitively impaired resident with epilepsy and vascular dementia, the most recent fall risk evaluation in the EHR was dated several years earlier and had not been updated quarterly as required by policy.

Staff interviews with CNAs, an LPN, the Resident Care Manager/RN, and the DON/RN confirmed that high fall risk residents should have beds in low position, doors open, frequent checks, and call lights within reach, and that these expectations applied to all residents, including those not on the falling star program. The DON stated it was standard practice for all beds to be at sitting level or lower and that call lights should be within reach of all residents. Despite these stated expectations and policies, survey observations and record reviews showed that for multiple high fall risk residents, beds were left in high positions, call lights and assistive devices were not within reach, and at least one resident’s fall risk assessment was not updated per policy, constituting the identified deficiency.