Failure to Maintain Required Fall-Prevention Device Within Reach
Penalty
Summary
Surveyors identified a deficiency related to accident prevention and supervision for a resident with a known history of falls. Resident #9 was admitted with diagnoses including type 2 diabetes mellitus with diabetic neuropathy, spinal stenosis, and major depressive disorder. An MDS 3.0 assessment documented that the resident was cognitively intact but dependent on staff for toileting and bathing and required supervision for personal hygiene. The resident’s care plan, dated 06/19/25, noted an actual fall and included an intervention to ensure a reacher (grabber) was accessible to the resident while in bed. A physician order dated 06/20/25 further specified that the resident required a reacher within reach every shift as an intervention. Despite these documented interventions and orders, observations on two separate days showed the reacher was not within the resident’s reach while he was in bed. On 02/17/26 at 11:00 A.M., an LPN observed Resident #9 lying in bed with the reacher placed on a chair against the opposite wall, and confirmed it was not within reach. On 02/18/26 at 10:30 A.M., the DON also observed the resident lying in bed with the reacher located across the room, again confirming it was not within reach. These findings demonstrated that the facility failed to implement the ordered and care-planned fall intervention for this resident with a history of falls.
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