F0689

G

Failure to Perform Root Cause Analysis and Individualize Fall Prevention After Multiple Resident Falls

Racine, Wisconsin Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision, thorough post-fall assessments, and timely, individualized care plan revisions to prevent accidents for multiple residents reviewed for falls. The facility’s own fall policy required completion of a fall risk assessment after every fall, evaluation of the area where the fall occurred for possible contributors, documentation of identified interventions, and 72-hour observation after a fall. However, for several residents, falls were not thoroughly assessed to determine root causes, contributing factors such as incontinence or transfer needs were not evaluated, and fall care plans were not promptly or appropriately updated to address identified risks.

One resident with diabetes, COPD, osteoarthritis, and a history of right fibula fractures was cognitively intact and occasionally incontinent of bladder, but had no toileting program and no assessment of incontinence as a fall risk factor. This resident had an unwitnessed fall in the bathroom while self-transferring from the toilet, resulting in facial bruising and swelling. The fall care plan was revised only to include re-education to call for assistance and placement of a “Call No Fall” sign, with no documented evaluation of urgency, frequency, or incontinence as contributors and no toileting-related interventions. Later, the same resident had an unwitnessed fall from bed resulting in a fractured right fibula; the fall scene investigation contained unclear handwritten notations, contradictory information about footwear, a blank root cause analysis section, and no documented assessment of bladder incontinence or toileting needs as potential contributors. The falls care plan was not revised after this second fall, and the resident’s bed was observed not in the lowest position despite documentation that this was an intervention.

Another resident with diabetes, orthostatic hypotension, cirrhosis with ascites, compression fracture, osteopenia, and atrial flutter was cognitively intact and required extensive ADL assistance, with an order for a blood thinner. The ADL care plan listed all transfer types and assistance levels without individualization. Therapy evaluated this resident and recommended maximum assistance of two with a non-motorized sit-to-stand device and gait belt, but this recommendation was not added to the ADL care plan before a witnessed fall occurred during a pivot transfer with one-person assistance. Staff reported that the CNA worksheet, derived from the care plan, contained multiple and conflicting transfer instructions, and the care plan had not been updated with the therapy recommendation until two days after the fall.

A cognitively intact hospice resident with spinal degeneration and Alzheimer’s disease had a falls care plan with generic interventions, including keeping the bed at an “appropriate height” without clarification. This resident had an unwitnessed fall from bed, stating they were trying to get to their son. The fall scene investigation documented impaired mentation and rolling out of bed as factors, but omitted key sections such as footwear, affect prior to the fall, recent medication changes, and environmental factors. The root cause was documented only as confusion, the interventions section was left blank, and there was no IDT root cause analysis form provided. The falls care plan was not revised until eight days later, when a fall mat was added, and later observation showed the bed at hip height with no fall mat in place.

Another resident with a stroke, left-sided weakness, cognitive impairment, and dependence on staff for dressing and hygiene had a falls plan of care with only generic interventions and no individualized fall prevention measures. The resident care guide’s safety section contained no fall interventions, despite the resident being incontinent and requiring one-person assistance for transfers and ADLs. This resident experienced multiple unwitnessed falls in the facility, including falls from bed that resulted in hospital transfers. For at least one fall, the documented root cause was that the resident “wanted something to eat,” but there was no supporting documentation for this conclusion and no documented interventions or care plan revisions to prevent recurrence based on that or any other possible etiology.

Across these cases, staff interviews revealed uncertainty about who was responsible for updating care plans after falls, with an LPN stating they had never updated a care plan and believed unit managers did so, and a unit manager acknowledging that root cause analyses had not been done for a period due to lack of unit managers. CNA worksheets used for daily care were generated from the care plans and, in at least one case, contained multiple, conflicting transfer instructions because the care plan itself was not individualized. These actions and inactions resulted in falls not being thoroughly assessed, root causes not being clearly identified or documented, and fall care plans not being promptly or adequately revised to address resident-specific risks such as incontinence, transfer method, bed height, and use of fall mats.