Failure to Implement Targeted Fall Interventions and Complete Post-Fall Neurological Assessments
Summary
The deficiency involves the facility’s failure to implement appropriate fall-prevention interventions, ensure needed mobility devices were within reach, and complete required post-fall assessments and notifications for a resident with severe cognitive impairment. The resident had multiple significant diagnoses, including senile degeneration of the brain, chronic respiratory failure with hypoxia, hypertensive heart disease with heart failure, chronic kidney disease stage IV, unsteadiness on feet, and lack of coordination. An MDS documented a Brief Interview of Mental Status score of 5/15, indicating severe cognitive impairment, and that the resident required supervision and contact assistance with toileting and used a wheelchair for mobility. On one date, the resident experienced an unwitnessed fall while attempting to get up to go to the bathroom and fell over a recliner chair footrest, striking her face on the floor. The fall investigation documented that the resident’s POA requested hospital transfer, and the resident returned with a small head laceration and no new orders. The facility’s fall log listed the intervention as ensuring the call light was within reach and functioning, an intervention that had already been in place and which the DON later confirmed was not appropriate for a resident with severe cognitive impairment. No new targeted interventions addressing toileting needs or the recliner footrest were documented after this fall. Later in the same month, the resident had another unwitnessed fall, was found on the floor, and could not state what happened. The only intervention documented was to educate the resident to use the call light and wait for assistance, which the DON again confirmed was not appropriate given the resident’s cognitive status. On a subsequent date, the resident had another unwitnessed fall while moving from one bed to another and was found on the floor between the bed and bathroom. The fall report documented a small bump to the head near the right eye, that vital signs were taken, the resident was helped back to bed, and again instructed to use the call light for help. The CNA who found the resident stated the wheelchair was across the room, out of the resident’s reach, despite a care plan intervention that assistive devices be kept within reach. The CNA reported the resident was mumbling, groaning, appeared in pain, had a large bump above the right eyebrow that swelled immediately, and was without oxygen. The CNA stated the LPN did not assess the resident, directed staff to get her up, and left the room, with another CNA later obtaining vital signs. The neurological assessment flow sheet initiated after this fall showed the resident as stuporous and unable to follow directions at the initial time, but all other required neurological and vital sign fields were left blank at that time and at all subsequent required intervals, with no nurse signature. The DON confirmed that neurological assessments were not completed, that there was no thorough investigation to determine root cause, and that appropriate notifications to family, physician, and hospice were not made. The MAR showed that ordered PRN lorazepam and morphine were not administered on the date of the fall, while family and hospice staff later reported the resident was lethargic, moaning, swollen and bruised, and appeared to have suffered a serious head injury and untreated pain. The facility’s own fall reduction and neurological assessment policies required evaluation for injury, neurological assessment for possible head injury, and timely notification of physician, responsible party, and hospice, which were not carried out in this case. Family members stated they were not notified of the fall when it occurred and only learned of it later, expressing that they would have come in immediately had they been informed. They also reported being told by a CNA that the nurse instructed CNAs to get the resident off the floor and back to bed without the nurse completing an assessment, and that the nurse said she would give morphine but was later observed at the desk on her phone and reading. Another LPN reported that when she came on duty the next day, there was no documentation that the prior LPN had completed neurological assessments or contacted the physician, hospice, or family, and that she herself then attempted to reach family and hospice, who came in right away. The hospice RN confirmed hospice was not notified until the following morning, despite hospice protocol requiring immediate notification of falls so hospice staff can assess the resident. The hospice RN described the resident as having been alert and conversational the day before the fall and as lethargic and unable to converse when seen the next morning, and stated that, based on her experience, the resident had likely sustained a concussion and brain bleed and needed earlier evaluation. The DON, after reviewing the fall investigations, care plans, assessments, neurological assessments, vital-sign documentation, interventions, and fall reports, confirmed that standard practice to thoroughly assess a resident post-fall was not followed. The DON verified that the interventions of reminding the resident to use the call light were not appropriate for a resident with severe cognitive impairment, that toileting should have been addressed after the first fall when the resident was attempting to go to the bathroom independently, that neurological assessments were not completed after the last fall, and that appropriate notifications to family, physician, and hospice were not made. The facility’s written policies on fall reduction and neurological assessment, which require evaluation for injury, use of neurological assessment guidelines for possible head injuries, and timely notification of physician, responsible party, and on-call nurse, were not adhered to in the resident’s case.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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