F0689

D

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

Mount Vernon, Washington Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and implement and update fall-prevention interventions for a resident with multiple falls. The resident was readmitted with epilepsy, congenital brain anomalies, muscle weakness, and difficulty walking, and the admission MDS showed no cognitive impairment. The resident required set-up assistance for toilet transfers and supervision/touching assistance for ambulation with a walker. Between mid-December and early February, the resident experienced nine falls. Incident investigations documented repeated falls related to self-transfers to a bedside commode (BSC), use of an unsafe four-wheeled walker, and environmental clutter, but the facility did not consistently translate identified issues into care plan updates, Kardex directions, or clear, implemented interventions.

One fall investigation on 12/17 documented that the resident fell while using a bedside table as a walker to self-transfer to the BSC, and the only documented intervention was a staff training note that one wheel of the bedside table needed to be locked at all times. However, the current care plan and nursing Kardex contained no instruction to keep the bedside table locked, and subsequent observations showed the bedside table remained unlocked. Another fall on 12/21 occurred when the resident, who required one-person assist for transfers and walking, walked without assistance to the front of the building and fell from a lobby bench; the investigation did not document any interventions to prevent further falls. A 12/24 investigation contained conflicting information about the type of walker used and the location and mechanics of the fall, concluded that the resident used an unsafe four-wheeled walker, and noted that the walker was removed and then given back to the resident, without documentation of risks/benefits education or additional interventions regarding the unsafe walker.

Further incident reports showed similar gaps. On 12/31, the resident slipped off the BSC, with predisposing factors including clutter, crowding, poor lighting, balance disorder, and ambulation without staff assistance; there was no documented conclusion or action taken. On 01/23, the resident again fell while using the BSC and an unsafe four-wheeled walker brought in by family, and although the record stated the resident wanted to use the walker despite education, there was no documentation of what risk/benefit information was provided. A 01/25 fall noted the resident was found on the floor after attempting to get up alone, with no documented conclusion or preventive action. On 02/02, the resident fell onto a box fan near the BSC in a cluttered room with a four-wheeled walker, fan, and BSC, and the call light out of reach; the report listed impulsive behavior, poor safety awareness, gait imbalance, and recurrent falls, but again lacked a documented conclusion, actions taken, or interventions addressing the cluttered environment.

The resident’s physical therapy evaluation on 01/27 documented the need for supervision or assistance with sit-to-stand, transfers, and toilet transfers, and moderate assistance for walking short distances. The existing fall care plan included older interventions such as placing the BSC close to the bed and ensuring the front-wheeled walker (FWW) was within reach, and encouraging use of both hands on the FWW, but these were not reflected in the actual room setup. Multiple observations in February showed the bed against the wall, a recliner in the middle of the room, the BSC about 10 feet from the bed behind the recliner, the bedside table unlocked next to the recliner, and no FWW in the room, while the four-wheeled walker was at the foot of the bed and away from the recliner. Staff interviews confirmed that the resident was a fall risk, frequently self-transferred to the BSC without using the call light, used an unsafe four-wheeled walker, and did not follow therapy recommendations, yet there was no documentation of detailed risk/benefit education to the resident and family, no consistent care plan updates, and no documented interventions to increase supervision despite staff acknowledging that personal caregivers were not present 24 hours a day.

Interviews with behavioral therapy staff and the DON further highlighted the lack of clear information and documentation. Behavioral therapy staff reported that nursing could not explain the multiple falls or the cause of the resident’s right eyelid injury, nor what interventions were in place to prevent further falls. The DON acknowledged that multiple falls were related to self-transfers to the BSC and use of the four-wheeled walker without supervision, and also acknowledged that the room arrangement and equipment placement did not match the resident’s needs, such as the BSC being behind the recliner and the walker not being placed near the recliner. The rehab director stated that the resident was not safe to use the four-wheeled walker and referenced a care conference where a collaborating agency staff member stated the resident had the right to use the preferred walker and the right to fall, but this conference was not documented. Overall, the facility did not adequately evaluate, document, or implement effective fall-prevention interventions in response to repeated falls, did not ensure the environment and equipment matched the care plan, and did not consistently update the care plan and staff directions to reflect the resident’s needs and identified risks.