F0689

G

Failure to Consistently Implement Fall-Prevention Interventions and Supervision for a High-Risk Resident

Colorado Springs, Colorado Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a high fall‑risk resident received adequate, person‑centered supervision and that fall‑prevention interventions identified in the care plan were consistently implemented. The resident was an older adult with traumatic subdural hemorrhage, seizures, dementia, generalized weakness, impaired mobility, impaired vision, cognitive communication deficit, and a history of multiple falls. The 1/14/26 MDS showed the resident was cognitively intact by BIMS but had fluctuating difficulty focusing attention and had already experienced multiple falls, including one with injury, since admission. The fall care plan, revised on 12/10/25 and 1/23/26, identified the resident as at risk for falls due to impaired mobility, history of falls, impaired vision, seizures, and psychotropic medication use, and called for specific interventions such as keeping the bed in the lowest position at all times, placing floor mats at the bedside, ensuring the call light and personal urinal were within reach, and moving the resident to a room across from the nurses’ station.

Surveyor observations showed that these care‑planned interventions were not consistently in place. On 2/24/26, the resident was observed in his wheelchair in his room, leaning forward toward the floor and beginning to fall forward with his legs buckling, while an RN sat at the nurses’ station across the hall but was not watching him until prompted. The RN then had to physically assist the resident back to a safe sitting position and instructed him to use his call light. On 2/26/26, the resident was observed sleeping in bed with the bed not in the lowest position, no floor mats at the bedside, and his personal urinal not within reach, despite the care plan requiring all three interventions to prevent falls. These observations demonstrated that the facility did not consistently provide the level of supervision and environmental controls it had identified as necessary for this resident.

The record review documented a pattern of repeated falls, many unwitnessed, with incomplete or inconsistent post‑fall analysis and follow‑through. The resident sustained multiple falls in the bathroom, from bed, from a low bed, during attempts to walk with a friend, and while attempting to transfer or reach for objects without assistance. On 11/22/25, he was found on the bathroom floor with root cause attributed to gait imbalance and an intervention to offer frequent toileting. On 11/24/25 and 11/26/25, he fell while attempting to walk with a friend and while trying to retrieve his cell phone, but the progress notes did not document a root cause analysis or review of the effectiveness of existing interventions or need for new ones. On 12/1/25 and 12/6/25, he was found on the floor after rolling or falling from bed, with one fall linked to toileting urgency and possible UTI, but again without consistent documentation of reassessment of interventions.

Further falls continued despite the resident’s high‑risk status and care‑planned interventions. On 12/9/25, he had two falls: one witnessed as he attempted to get out of bed unassisted, and a later unwitnessed fall in which he was found on the floor bleeding from lacerations to his forehead and jaw after attempting to empty a urinal without using his call light, resulting in transfer to the hospital for treatment. On 12/10/25, he reported sliding from bed and getting himself back in, and on 12/16/25 he fell in the shower room after sliding from the shower chair while reaching to turn off the water; the CNA had left him unattended in the shower room for a few minutes, even though the DON later stated that a resident with a high fall‑risk diagnosis should not be left alone there. On 12/31/25, he fell while trying to get into bed when he could not find his call light, which had fallen and become wrapped around the wheelchair wheel, and on 1/19/26 he fell in the bathroom while transferring from the toilet to his wheelchair without assistance when the wheelchair was not locked. Staff interviews confirmed that the resident was very impulsive, had been falling frequently, and required close supervision, yet the documented lapses in supervision, inconsistent implementation of care‑planned interventions, and incomplete root cause analyses after several falls led surveyors to conclude that the facility failed to provide adequate supervision and consistently implement person‑centered fall‑prevention measures for this resident.