F0689

E

Failure to Evaluate and Modify Fall-Prevention Interventions and Complete Post-Fall Neuro Checks

Palm Springs, California Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that fall-prevention interventions for a resident with multiple falls were evaluated for effectiveness and modified appropriately. The resident was admitted with diagnoses including cognitive communication deficit, syncope, and collapse, and had a known history of falls prior to admission. Progress notes document repeated unwitnessed falls beginning in June and July 2025, often with the resident found on the floor next to the bed, sometimes stating he was reaching for something or trying to get up. The resident was described as alert with confusion, lacking safety awareness, and not following fall precautions, and the IDT identified the falls as likely related to behaviors, spontaneous movements, and limited cognitive ability for safety.

Across multiple IDT meetings, various fall-related issues were discussed, but interventions were not consistently implemented or updated in response to repeated falls. In July 2025, the IDT discussed several unwitnessed falls and noted the resident’s confusion and behavioral component, planning bilateral fall mats, a psych referral, and encouraging time in a wheelchair at the nurses’ station. In September 2025, after another fall, the IDT noted the resident slid off the bed while trying to get up and documented existing interventions such as a geri chair, fall mats, and possible bed alarm. Later in September, after another fall, the team considered bilateral bolsters in bed to mitigate rolling off the bed, but subsequent progress notes in October 2025 did not indicate that these bolsters were in place, and there were no new interventions implemented after the September 22 fall despite additional falls on October 17 and October 25, 2025. The resident continued to report rolling out of bed or acting on confused perceptions, such as chasing animals he believed were in the room.

The facility also failed to complete required post-fall neurological assessments for this resident following unwitnessed falls. Review of Post Fall-Neurological Check documents showed multiple missing entries for vital signs and neurological parameters over several dates. On various dates in July, August, and September 2025, documentation lacked pulse, respirations, assessments of pupils and extremities, and evaluations for seizure, headache, nausea, or vomiting. Several shifts had no entries for respirations, level of consciousness, response, or speech, and some entries lacked times or dates. The DON confirmed that neurological assessments are required for 72 hours after unwitnessed falls or possible head injury and acknowledged that these assessments were not completed as required for this resident. The facility’s fall management policies required individualized care plans with measurable objectives, post-fall risk evaluations, 72-hour follow-up documentation, neurological assessments after unwitnessed falls, investigation of causal factors, and care plan updates, but the documented record for this resident showed repeated falls without consistent modification of interventions and incomplete post-fall neurological monitoring.

Additional documentation showed that orders for alarms and supervision were present but not clearly tied to effective modification of the care plan in response to ongoing falls. Physician orders in November 2025 allowed the resident to be up in a geri chair when not in bed and permitted use of tab alarms and alarm pads in bed and chair to remind the resident to call for assistance and alert staff to unsupervised transfers or ambulation. The DON stated that the resident had been moved closer to the nurses’ station for better supervision and that when up in a geri chair he was to be near the nurses’ station, but there was no care plan or order for a sitter. The DON also stated that a psychology consult was ordered in July 2025 but could not find documentation that it was completed. Overall, the record shows that despite multiple falls and identified behavioral and cognitive risk factors, the facility did not consistently evaluate the effectiveness of fall interventions, did not reliably implement or document planned interventions such as bed bolsters and psych evaluation, and did not complete required 72-hour neurological assessments after unwitnessed falls, leading to the cited deficiency.

The resident’s care plan documented actual falls on October 17 and October 25, 2025, with interventions including a fall mat, low bed, keeping items within reach, neuro checks, non-skid footwear, and monitoring and documentation for 72 hours. However, the pattern of repeated falls and the gaps in neurological check documentation demonstrate that these interventions and monitoring requirements were not fully carried out or adjusted in response to ongoing incidents. The facility’s own fall management policies required reassessment of fall risk with significant changes in condition and updating of the care plan after each incident, but the clinical record for this resident shows that after certain falls, such as the October 17 event, no new interventions were added beyond those previously considered, and recommended measures like bilateral bolsters were not clearly implemented. These documented inactions and incomplete assessments form the basis of the deficiency related to accident hazards and inadequate supervision to prevent accidents for this resident.