F0689

D

Failure to Maintain Line-of-Sight Supervision and Complete Neuro Checks After Unwitnessed Fall

Muscoda, Wisconsin Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and implementation of fall-prevention interventions for a resident at high risk for falls, as well as failure to complete required neurological assessments after an unwitnessed fall with head injury. The resident had multiple diagnoses including inflammatory spondylopathy of the lumbar region, COPD, acute on chronic systolic CHF, type 2 diabetes with diabetic polyneuropathy, post-stroke cognitive symptoms, muscle wasting and atrophy, unsteadiness on feet, and bilateral age-related cataracts. An MDS assessment showed a BIMS score of 99, indicating severe cognitive impairment. Fall Risk Evaluations conducted on several dates showed the resident was consistently at risk for falls, with scores of 10, 19, 15, and 11. The resident’s care plan identified her as at risk for falls related to medications, dizziness, cognitive impairment, and unawareness of safety, and included multiple interventions such as use of an appropriately sized Broda chair, environmental monitoring, low bed position, call light within reach, use of a gait belt, and later, a “Falling Star” check every 60 minutes.

Following an unwitnessed fall on 9/25, the resident’s care plan was updated on 9/26 to include the specific intervention that she must remain within eyesight when up in her Broda chair. Additional fall-related care plan updates on 9/28 included directions to evaluate fall risk on admission and as needed, to alert the provider if a fall occurs, and to initiate frequent neurological and bleeding evaluations per facility protocol after a fall. The facility’s Fall Management Process policy required a complete head-to-toe assessment before moving a resident after a fall, neurological checks for any unwitnessed fall or any fall with evidence of head injury, and documentation of physician and family notification. Despite these policies and care plan directives, the resident experienced further unwitnessed falls, including one on 11/1 while walking unsupervised in her room and attempting to self-transfer from bed, and another on 11/2 when she fell from her wheelchair in the hallway.

On the night of 11/2, the resident was in her Broda chair and was supposed to be kept within line of sight of staff per her care plan. A CNA’s written statement indicates the CNA and another staff member were at the nurses’ station gathering paperwork while the resident was on the other side of the nurses’ station near the medication cart and within the CNA’s view. The CNA reported that less than five minutes after last seeing the resident, she noticed the resident was no longer by the medication cart, saw the wheelchair down the hall without the resident in it, and then found the resident lying on her right side on the floor in front of a room. A progress note documented that the fall was unwitnessed and occurred in the hallway. A subsequent assessment identified a hematoma on the resident’s forehead measuring 6.5 x 5 (unit not specified), and progress notes documented the presence of pain. Although neurological assessment forms were completed at multiple time points, many entries simply recorded the resident as “asleep” for all categories, and there were no neurological assessments documented at specific times when the resident was known to be awake (such as when she received morphine and lorazepam or when she self-transferred to the bathroom). Interviews with facility staff, including a medication tech, an RN, the NHA, and the DON, confirmed that “in line of sight” means staff must be able to physically see the resident, and that a proper neurological exam cannot be performed if the resident is asleep because pupils and other parameters must be assessed. The surveyor noted that the facility could not provide documentation showing the resident was in line of sight at the time of the fall from the Broda chair, and that neurological checks were not completed in accordance with policy after the unwitnessed fall with head injury.

Interviews with the NHA and DON further confirmed that residents with fall precautions are identified by star pictures on their doors and interventions listed on care plans and closet Kardexes, and that residents with “in line of sight” interventions must be physically visible to staff. The DON stated she would wake a resident to complete a neurological assessment because otherwise she would not know if there had been a change in mental status, and she identified pupil size and vital signs as pertinent findings on neurological assessments. Despite these expectations, the documentation for this resident showed repeated use of “asleep” entries in place of full neurological assessments, even after an unwitnessed fall with a documented forehead hematoma. The surveyor allowed additional time for the NHA and DON to locate any alternative evidence that the resident had been kept within line of sight at the time of the 11/2 fall, but none was provided. These findings demonstrate that the facility did not ensure the resident received adequate supervision in accordance with her care plan and did not complete neurological checks as required by facility policy after an unwitnessed fall with evidence of head injury.