F0689

G

Failure to Implement and Follow Through on Fall Interventions for a Cognitively Impaired Resident

Troy, Michigan Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement adequate and effective fall interventions and to consistently follow up on fall-related interventions for a resident with dementia, Alzheimer’s disease, a history of falls, major depressive disorder, glaucoma, and a prior nasal bone fracture. On admission, the resident’s MDS showed a BIMS score of 3, indicating severely impaired cognition and a need for staff assistance with all ADLs. The admission fall assessment categorized the resident as “No Risk” with a score of 9.0, and a fall care plan was initiated with general interventions such as encouraging appropriate footwear, maintaining a safe environment, keeping the call light and commonly used items within reach, and PT/OT evaluation as ordered or PRN. The resident also had impaired communication related to confusion and a primary language of Arabic, contributing to a language barrier.

Following admission, the resident experienced multiple falls and fall-related events, many of them at night and some unwitnessed. On one occasion, the resident was found on the floor after attempting to reposition in bed; on another, staff documented that the resident was “constantly sliding himself out of bed and onto floor.” A telehealth note described an unwitnessed change in elevation with the resident found on the bedroom floor. The IDT later identified a root cause that the resident dropped a book and attempted to pick it up, and the care plan was updated to include therapy assessment for assist bars to improve bed mobility and a reacher for hard-to-reach items. However, therapy records showed the resident was never assessed by PT/OT for these interventions. The resident continued to have unwitnessed falls, including in the common area, where staff noted agitation, yelling, and a language barrier that made it unclear what was bothering him.

As falls continued, the facility’s response increasingly focused on psychotropic and anti-anxiety medications rather than documented, completed environmental or functional interventions. Orders were initiated and adjusted for Alprazolam (Xanax), Ativan, and Seroquel for anxiety, agitation, and behaviors, including scheduled and PRN dosing, while the resident continued to experience falls from bed and the floor, often while trying to reach items such as a phone charger. A concave mattress was added after repeated falls from bed, and the IDT documented plans such as requesting a longer phone cord and educating the family about fall safety and not leaving the resident alone when restless. The DON later confirmed that there was no documentation that the resident had been assessed by therapy for assist bars and a reacher, despite this being a documented care plan intervention. The DON also stated the resident was placed in the common area at night for increased supervision, even though a fall had occurred there as well, and could not provide further documentation of additional assessments.

Ultimately, after a series of falls and ongoing agitation, the resident’s daughter requested transfer to the hospital due to concerns about frequent falls and care. EMS documentation noted altered mental status, difficulty determining baseline, and conflict between family and facility staff that delayed departure. In the emergency department, the resident was evaluated for generalized weakness, multiple falls, and foul-smelling urine. Imaging of the pelvis revealed a mildly displaced avulsion-type fracture of the left ischial tuberosity at the common hamstring origin. The final hospital impression included urinary tract infection, generalized weakness, and a left ischium fracture. The surveyors concluded that the facility failed to implement adequate/effective fall interventions and ensure consistent follow-up of fall interventions for this resident, resulting in a hospital transfer and identification of the left ischium fracture.

The facility’s own fall management policy required identification of hazards and resident risk factors, implementation of interventions to minimize falls and injury, and provision of adequate supervision, assistive devices, and functional programs, coordinated by the DON/designee through an interdisciplinary process. Despite this policy, the record showed that key planned interventions, such as PT/OT assessment for assist bars and a reacher, were not carried out, and that the resident, who had severe cognitive impairment, communication barriers, and repeated falls, continued to experience falls without documented completion of the specified interventions and without clear evidence of effective adjustment of the fall prevention plan in response to the ongoing events.