F0689

G

Failure to Communicate and Implement Fall-Prevention Interventions for High-Risk Resident

Myrtle Beach, South Carolina Survey Completed on 02-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and accident prevention for one resident with a known high risk for falls, resulting in a right 11th rib fracture after a fall. Facility policy on "Accidents and Supervision" required identification of hazards and risks, implementation of interventions to reduce those risks, communication of interventions to all relevant staff, and documentation and monitoring of those interventions. The resident, admitted with diagnoses including muscle weakness, cognitive communication deficit, limitation of activities due to disability, and aphasia, had a Quarterly MDS showing a BIMS score of 4/15, indicating severe cognitive impairment, and was dependent on staff for transfers and ambulation. A Morse Fall Scale completed at admission identified the resident as high risk for falls, and the care plan included a focus on fall risk with interventions such as keeping the call light within reach, anticipating needs, and offering assistance to bed after dinner.

The resident had a prior fall on 08/08/2025 when transferring from a recliner without assistance, which was documented by the DON. Following that fall, the interdisciplinary team determined an intervention to offer assistance to bed after dinner, and this intervention was added to the care plan. On 09/02/2025, the resident again fell while attempting to get out of a geriatric recliner without assistance after dinner. The fall was unwitnessed; the resident reported hitting their head and having shoulder pain, with a small amount of bleeding from the right ear and redness on the right side of the back noted. The MD, who encountered the resident sitting on the floor, assessed the resident and ordered transfer to the emergency room, where imaging showed a right 11th rib fracture and a urinary tract infection. Documentation indicated the resident had been seen sitting in a recliner around the time dinner trays were picked up and fell when attempting to get up without assistance.

Interviews revealed that key fall-prevention interventions were not effectively communicated or implemented by staff. CNA2, who was assigned to the resident at the time of the fall, stated she learned about fall interventions from nurse report, had never been told to assist this resident to bed after dinner, and did not recall when she last saw the resident before the fall. CNA2 reported that the resident’s call light was on the bed next to the resident’s chair, within reach, but the resident had severe cognitive impairment. LPN1, who responded after the fall, stated she had never accessed care plans at the facility and relied on experience and knowledge of residents rather than reviewing care plans; she believed the only intervention in place was to check on the resident frequently and stated the resident could not use a call light appropriately or understand its purpose. The UM and MDS Coordinator described a process in which post-fall interventions were added to care plans and Kardexes, with an expectation that nurses would communicate changes to CNAs, but there were differing understandings about CNA access to care plans and Kardexes. The DON and ED stated they expected interventions, including new fall interventions, to be communicated to staff and implemented, and the DON acknowledged responsibility for ensuring fall interventions were updated and accessible. Despite the prior fall from a recliner and the care-planned intervention to assist the resident to bed after dinner, the resident was again left in a recliner after dinner without effective supervision or assistance, leading to another fall and injury.