Failure to Implement Fall Prevention Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions to prevent and/or minimize injury for a resident identified as very high risk for falls, resulting in multiple unwitnessed and witnessed falls. Staff interviews and record review showed that the resident had dementia, confusion at baseline, insomnia, hearing loss, major depressive disorder, adjustment disorder with depressed mood, and a history of repeated falls. Progress notes documented that the resident was aggravated and attempting to crawl out of bed, had a witnessed slide from bed with a resulting skin tear, and later experienced additional falls. Nursing staff, including LPNs and the DON, acknowledged that the resident was a definite fall risk, was very agitated, kept trying to get out of bed, and was unable to walk independently. Despite this, the resident did not have floor mats in place at the time of at least one fall, and staff reported that fall mats were not used initially because they believed the resident would trip over them. The resident’s care plan identified a potential to fall and risk of injury from falls, with an intervention for a one‑inch floor mat to be placed beside the bed beginning on a specified date. However, staff statements and documentation showed that the floor mat intervention was not consistently implemented, including after the resident returned from the hospital with a scalp laceration requiring staples and other injuries from a prior fall. One LPN reported hearing a “thud” from the nurse’s station and finding the resident face down on the floor with blood around the head, noting that no fall mat had been placed because of concern the resident would trip. The DON stated that a one‑inch floor mat was implemented only after the second fall that shift, and the resident subsequently fell again about an hour after returning from the hospital. Hospital records confirmed that the resident sustained multiple cervical vertebral fractures, nasal and septal fractures, a tooth fracture, scalp laceration, and blunt head trauma as a result of three falls within 24 hours, and the death certificate linked the resident’s death to multiple vertebral fractures due to falls.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.