F0689

D

Failure to Implement Timely Post-Fall Interventions and Care Plan Updates

Ludington, Michigan Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its fall prevention policies and to implement timely, meaningful care plan interventions after falls for a resident with significant fall risk factors. The resident had Parkinson’s disease, Parkinsonism, and dementia, and was care planned as being at risk for falls related to confusion, deconditioning, gait/balance problems, incontinence, and Parkinson’s. On one occasion, a housekeeper approached the resident’s room and observed the resident standing and pivoting to his walker when his foot became stuck in the walker wheel, causing a loss of balance and a fall. The resident sustained a skin tear to the back of the right hand. Staff statements indicated that a CNA had just left the room after providing care, the resident had been in his chair, and an alarm was sounding at the time of the fall.

Following this fall, facility documentation identified root causes including anxiety, terminal restlessness, Parkinson’s, loss of balance, and impaired balance with unawareness of safety needs. However, the Nurse-Risk Management Note stated only that all safety interventions were in place and did not document meaningful post-fall interventions. A Fall Packet/Investigation Checklist indicated that q15-minute safety checks were to be added to the plan of care, but the care plan did not reflect the addition of these 15-minute safety checks. The facility’s Fall Prevention Program policy required ongoing identification of residents at risk for falls, assessment of current interventions for effectiveness, and implementation of new interventions after each fall based on root cause analysis, including interim safety measures within the first 24 hours if needed.

On a subsequent date, the resident experienced another fall, this time unwitnessed, after a CNA heard the chair alarm and found the resident on the floor in front of the recliner chair. Documentation suggested the resident likely slipped on a blanket or slippers while attempting to self-transfer. The root cause analysis for this fall again cited terminal restlessness and that it was unsafe for the resident to be in the room in a chair without supervision, concluding the resident should not be in a chair in the room alone. The resident was supposed to be on q15-minute checks per the prior fall investigation, and the Fall Packet/Investigation Checklist for this second fall noted that q15-minute safety checks were already on the plan of care, yet no new interventions were initiated or added. The fall care plan did not timely reflect the intervention that the resident should not be left alone in the room recliner, and the DON acknowledged concerns about the timeliness of implementing care plan interventions and not following the care plan to prevent a fall.