F0689

G

Failure to Consistently Implement Person-Centered Fall-Prevention Interventions

Westminster, Colorado Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure person-centered fall interventions were consistently implemented for two residents identified as being at risk for falls, resulting in multiple unwitnessed falls and injuries. One resident with hemiplegia, vascular dementia, severe cognitive impairment, wandering behavior, and a history of frequent falls was care planned as high risk for falls with multiple individualized interventions, including use of a communication board, low bed, anti-rollbacks and anti-tippers on the wheelchair, grip tape on the floor, scheduled toileting assistance, a soft-touch call light, and relocation of the room closer to the nurses’ station. Despite these identified needs and interventions, the resident experienced several unwitnessed falls in her room and bathroom, including one fall where she hit the back of her head and required five stitches. Progress notes documented that many of her falls occurred when she attempted to use the bathroom independently.

During surveyor observations, staff actions and inactions showed that these person-centered interventions were not consistently implemented. The resident was observed sitting on the edge of her bed, unstable on her feet, attempting to manipulate her wheelchair and reach for items out of her reach without staff assistance. She was assisted to the bathroom by an LPN, who then left her alone and did not return, despite the resident’s known high fall risk and history of attempting to toilet independently. The resident did not use her call light and repeatedly self-transferred between the toilet and wheelchair and self-propelled in and out of her room and into the hallway without staff assistance or supervision. Although the interdisciplinary team had previously added a communication board to help the resident express her needs and reduce frustration that led to unsafe ambulation, staff were not observed using a communication board with her. Additionally, after the physician documented that a low bed was being ordered to help prevent further falls, observations showed the resident’s bed was not in a low position.

The second resident had dementia, severe cognitive impairment, a history of falls, and documented pelvic fractures, and was care planned as being at moderate risk for falls with specific interventions. These interventions included ensuring the call light was within reach, providing proper footwear such as tennis shoes or non-skid socks, educating the resident to lock wheelchair brakes prior to self-transfer, providing contact guard assist for transfers, placing a fall mat at bedside when the resident was in bed, and keeping the bed in the lowest position. The resident had multiple documented falls, including falls resulting in pelvic fractures and a fall from bed with head involvement and a hematoma. Despite these identified risks and interventions, surveyor observations found the resident in bed without a fall mat in place, with the fall mat folded against the wall, and the bed not in the lowest position or locked. The resident was also observed self-transferring from wheelchair to bed and sitting in her wheelchair wearing regular socks without appropriate footwear, while the bed remained unlocked. Staff entering the room did not correct the absence of the fall mat or the unlocked bed, and the care plan did not document that the resident refused these fall-prevention interventions.