F0689

D

Failure to Provide Adequate Supervision and Person-Centered Fall Prevention

Milwaukee, Wisconsin Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision, assistance, and person‑centered fall prevention interventions for residents at high risk for falls, and failure to conduct thorough post‑fall investigations with root cause analyses. One resident was admitted with multiple diagnoses including a history of falls, dementia, Alzheimer’s disease, weakness, impaired mobility, and cognitive deficits. Hospital documentation prior to admission showed this resident required bed and chair alarms and had significant safety‑awareness and functional limitations. On admission, the facility’s fall risk assessment identified the resident as high risk for falls, and PT/OT evaluations documented balance deficits, decreased safety awareness, impaired judgment, and a high risk for further falls without skilled interventions. Despite this, the baseline care plan and Kardex contained generic, incomplete, and non‑person‑centered interventions such as “call light within reach,” “follow facility fall protocol,” and unspecified assistance levels for bed mobility, transfers, ambulation, and ADLs, without clear instructions to staff on how to safely care for the resident.

Within approximately 48 hours of admission, this resident experienced three falls. The first two falls on the same day were unwitnessed, and documentation by the LPN noted the resident was found on the floor, assessed as alert and oriented to one, with neuro checks documented and vital signs stable. The resident was assisted back to a wheelchair and placed in common areas for supervision. However, when the surveyor requested the fall investigation for the first unwitnessed fall, the facility could not provide a completed investigation with root cause analysis, and there were no staff statements describing where in the room the resident was found, what the resident had been doing, or other contextual details such as continence status. For the second unwitnessed fall, the facility’s fall investigation form lacked clarity about where the resident had been last seen (bed or chair), how far the resident moved before being found on the floor under a chair, and how the resident sustained a bump to the right side of the head. There were no staff witness statements, and no documented root cause analysis or detailed investigation of contributing factors. The surveyor also noted there was no RN assessment documented after the first fall.

The third fall for this resident was a witnessed fall at the nurses’ station, where the resident had been kept under supervision after the earlier events. Nursing documentation described the resident as confused, refusing to sit, fighting and scratching staff, verbally expressing a desire to fall, and pulling out oxygen tubing. The nurse reported that the resident suddenly stood up and fell, sustaining a head laceration that required emergency room evaluation. When the surveyor requested a fall investigation and root cause analysis for this event, the facility again was unable to provide one, and there were no staff statements detailing what specific interventions were attempted to manage the resident’s agitation and maintain safety at the nurses’ station. The DON later acknowledged that there were no person‑centered fall interventions in place for this resident despite the known high fall risk and prior hospital documentation.

A second resident, also identified as high risk for falls based on a fall risk assessment, had a care plan that listed only generic interventions such as keeping the call light within reach, ensuring appropriate footwear, and following facility protocol. This resident experienced an unwitnessed fall while getting out of bed. The fall investigation form documented that the resident was found on the floor and that the call light was within reach, but the witness statement indicated, “I didn’t see anything.” The investigation did not include additional staff statements or information about when the resident was last seen or last toileted before the fall. When questioned, the DON confirmed that the facility had no further information regarding the timing of the last observation or toileting. Across both residents, the facility did not complete thorough post‑fall investigations or root cause analyses and did not develop or revise individualized, person‑centered interventions to address identified fall risks.