F0689

E

Failure to Revise Fall-Prevention Interventions for High-Risk Resident

Trinity, Texas Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and develop and implement effective fall-prevention interventions for a cognitively impaired resident with a significant history of falls. The resident was an older male with metabolic encephalopathy, lack of coordination, bipolar disorder with psychotic features, muscle weakness, muscle wasting and atrophy, a lumbar compression fracture, and a documented history of falls. His quarterly MDS showed a BIMS score of 6, indicating moderate cognitive impairment, and he required partial to moderate assistance with sit-to-stand and bed-to-chair transfers. The care plan identified him as high risk for falls due to confusion, impaired balance, incontinence, unawareness of safety needs, narcotic and psychotropic medication use, poor balance, and unsteady gait, and noted that he would attempt to transfer from bed to chair without assistance.

Despite this high fall risk, record review showed the resident experienced repeated falls over several months, including multiple falls on the same day and both witnessed and unwitnessed events in his room and other facility areas. Facility documentation listed numerous falls across June, July, August, and September, including six separate falls on one date and at least two falls with injury, one of which resulted in a laceration and another that led to EMS transport and hospital evaluation for altered mental status. EMS and hospital records noted a known history of multiple falls and visible bruising in various stages of healing, including to the face and a bandaged wound to the forearm. Interviews with staff and family confirmed that the resident had frequent falls and multiple bruises over his body from these events.

Interviews revealed that the resident was described as impulsive, defiant at times, and often refused to use his call light, instead attempting to transfer himself, particularly to go smoke. The Administrator, DON, ADON, LVN, and CNAs reported that the resident would “throw himself” during transfers from bed to chair or chair to bed and that most falls occurred when he attempted to transfer without assistance, often from wheelchair to bed. Staff stated that interventions in place included lowering the bed, placing fall mats, ensuring call lights were in reach, rearranging the room, frequent checks, therapy involvement, pharmacy reviews, and, at times, one-on-one supervision when behaviors were “really bad.” However, the DON acknowledged that, despite a fall timeline showing multiple recurrent falls, there were no new interventions implemented with each fall. The facility’s own fall policy required assessment after each fall, identification of causes and patterns within 24 hours, and modification of interventions when falls recurred, but the record review and interviews showed that interventions were not consistently revised in response to the resident’s ongoing falls and behaviors.

Additional interviews indicated gaps in staff training related to behavioral management for residents with challenging behaviors. CNA A, who frequently cared for the resident, reported that she had not been trained on the facility’s policy related to residents with behaviors, although she had EMT training from outside the facility. LVN A also stated she had not received behavioral training at the facility, relying instead on prior nursing experience. Staff and administration reported that the resident’s behaviors and falls worsened after the family installed cameras in his room and the family member began waking him for smoke breaks and speaking to him through the camera, which prompted him to attempt transfers despite his weak legs and dementia. The combination of the resident’s high fall risk, repeated falls with injuries, lack of consistent modification of interventions after each fall, and incomplete behavioral-specific training for staff led to the identified deficiency in providing adequate supervision and assistive devices to prevent accidents.

The facility’s written policy, “Assessing Falls and Their Causes,” required that after each fall, staff assess the resident, identify potential causes and patterns within 24 hours, and modify interventions when falls continued despite existing precautions. However, the DON’s review of the fall timeline and her statement that there were no new interventions with each fall demonstrated that this policy was not followed for this resident. Staff interviews consistently described the resident as frequently falling, having multiple bruises, and being known to throw himself during transfers, yet the interventions remained largely unchanged over time. This failure to adjust the care plan and interventions in response to the resident’s ongoing falls and behaviors, in the context of his complex medical and cognitive conditions, formed the basis of the deficiency for not ensuring the area was free from accident hazards and not providing adequate supervision to prevent accidents.