F0689

G

Failure to Implement Effective, Individualized Fall Prevention for High-Risk Residents

Twinsburg, Ohio Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, individualized, and effective fall management program and to ensure fall-prevention interventions were in place for multiple residents at risk for falls. One resident with moderate cognitive impairment, a history of repeated falls, impaired mobility, and multiple comorbidities experienced at least seven falls over several months, culminating in an unwitnessed fall with an orbital fracture. Despite documented fall risk assessments identifying at least moderate and later high fall risk, the facility repeatedly relied on generic interventions such as a “call before you fall” sign and resident education, without evidence these were appropriate or effective given the resident’s cognitive status and functional limitations. Post-fall assessments and IDT notes did not reflect meaningful root cause analysis or individualized modifications to the care plan, and fall investigations were not provided for review.

For this same resident, the facility did not timely identify and act on a suspected urinary tract infection that was associated with lethargy, altered mental status, and increased confusion. A CNP ordered a urinalysis and culture to evaluate for a possible infectious cause of acute delirium, but the urine specimen was not collected until weeks later, and the abnormal results showing nitrite-positive urine and a culture with greater than 100,000 E. coli were not communicated to a provider as required. During this period, the resident continued to have falls, including a fall with major injury. The resident’s daughter reported noticing increased confusion and unusual behaviors and stated she had requested a UA earlier; she later discovered the positive results herself and reported that treatment was only initiated after she confronted staff. Medical literature cited in the report recognizes UTIs as a contributor to increased fall risk in elderly residents, and the facility’s own policy identifies infection as a condition that may contribute to fall risk.

Additional deficiencies were identified for three other residents with documented fall risks and care-planned interventions that were not implemented as written. One resident with severe cognitive impairment, traumatic brain injury, and multiple fractures had a care plan requiring the bed to be kept in low position, a pillow for positioning, and floor mats on both sides of the bed; surveyors observed the bed raised, only one mat in place, the second mat leaning against the wall, and no positioning pillow in use. Another resident with severe cognitive impairment, high fall risk, and a history of a cervical spine fracture with a c-collar had care-planned interventions including a low bed, a fall mat on a specified side, and a call light within reach; surveyors found the bed raised, the mat on the wrong side, and the call light on the floor behind the head of the bed, out of reach. A fourth resident with severe cognitive impairment, high fall risk, dementia with behavioral disturbance, and psychosis had a care plan calling for bed pillows for positioning and a call light within reach, but surveyors observed no positioning pillows and the call light stored in a closed nightstand drawer. In each case, staff confirmed that the observed conditions did not match the residents’ fall-prevention care plan interventions, contrary to the facility’s falls policy requiring staff to implement interventions based on identified risks and causes.

The facility’s undated Falls and Fall Risk, Managing policy stated that, based on evaluations and current data, staff would identify interventions related to each resident’s specific risks and causes to try to prevent falls and minimize complications, and that fall risk factors include incorrect bed height or width and conditions such as infection. However, surveyors found repeated instances where beds were not in low position, mats were missing or improperly placed, call lights were not accessible, and individualized interventions were either not implemented or not adjusted after repeated falls. The quarterly MDS assessments for at least two residents were also inaccurate, failing to capture documented falls, including one fall that resulted in a six-day hospitalization and another that caused a cervical spine fracture. These inaccuracies further reflected the facility’s failure to maintain accurate assessment data related to falls and fall risk, contributing to the overall deficiency in accident prevention and supervision.