F0689

G

Failure to Implement and Communicate Person-Centered Fall Interventions After Multiple Falls With Injury

Alamosa, Colorado Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident remained free from accidents by not timely implementing person-centered fall interventions and not updating care plans after multiple falls. The facility’s fall management policy required assessment upon admission, with changes in condition, and after any fall, with individualized interventions and IDT review and revision of the care plan as indicated. For this resident, the fall prevention care plan listed general interventions such as orientation to room, diversionary activities, referral to PT, use of a soft helmet, and provision of adaptive equipment, but did not specify what adaptive equipment or devices were needed. Despite a PT evaluation identifying a change in the resident’s functional status and need for supervision or touching assistance with ambulation, the fall prevention care plan was not updated to reflect this new level of assistance.

The resident, an individual over 65 with Alzheimer’s disease, dementia, severe cognitive impairment, disorganized thinking, daily wandering, gait abnormality, muscle weakness, and multiple other diagnoses, experienced several falls with injuries. The record shows a witnessed fall where the resident tripped while two staff assisted him to the restroom, resulting in knee abrasions; the behavior huddle note following this event only addressed behavior interventions and did not include a post-fall review or new fall-prevention interventions. Another witnessed fall occurred when the resident was struck by another resident, causing a head laceration requiring staples in the ED; there was no documentation that the IDT reviewed this fall or recommended fall-prevention interventions. An unwitnessed fall later occurred in the resident’s room, with a hematoma on the back of the head and documentation that the resident wore big, bulky shoes; again, there was no IDT review or new interventions documented.

Subsequently, the resident had a witnessed fall in the hallway when staff attempted to redirect him from a distance to sit in a chair; he missed the chair and fell, sustaining arm and elbow injuries. A CT scan later showed a subdural hematoma with midline shift. Nursing documentation noted that a four-wheel walker was provided, but the resident did not use it correctly, became aggressive when cued, and the nurse considered the walker a tripping hazard; the IDT post-fall note from this period contained no additional fall-prevention recommendations beyond a declined request for sleep medication. Another unwitnessed fall occurred in the hallway outside the resident’s room, during which he yelled out in pain and clutched his left hip; hospital records documented a left hip fracture, multiple rib fractures, and thoracic spine fractures. Across these events, staff interviews revealed CNAs were unsure of alternative safe ambulation options, reported that the resident walked around the unit by himself, and described difficulty providing continuous monitoring due to other tasks and lack of coverage during breaks. The DON acknowledged a breakdown or delay in communicating PT’s change in ambulation assistance needs to nursing staff, and there was repeated lack of documented IDT review and revision of the fall care plan after multiple falls with injury.