F0689

E

Failure to Provide Consistent Post-Fall Monitoring and Implement Care-Planned Fall-Prevention Interventions

Sheboygan, Wisconsin Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision, consistent implementation of fall-prevention interventions, and complete post-fall assessments, including timely vital signs (VS), for four residents. Facility policy dated 1/21/26 required individualized fall-prevention interventions to be implemented consistently and post-fall monitoring with documentation of the resident’s condition at least every shift for 72 hours, including VS and other relevant clinical findings. Despite this, multiple post-fall assessments for several residents lacked updated VS, and some required fall-prevention interventions were not implemented as care-planned.

One resident with dementia, hypertension, anxiety, right-sided hemiplegia, and severe cognitive impairment (BIMS 0/15) was at high risk for falls and at risk for bleeding and excessive bruising related to anticoagulant therapy. This resident had an unwitnessed fall in the room on 1/10/26 and was found on the floor, incontinent of urine and unable to report what happened. The fall investigation identified impulsive behavior, decreased safety awareness, and cognitive impairment as root causes, and an immediate intervention was added to ensure gripper socks were on both feet. However, the care plan revised on 1/28/26 did not contain the gripper sock intervention. Post-fall assessments did not begin until approximately 48 hours after the fall, and three of eight documented post-fall assessments used VS obtained many hours earlier rather than updated VS at the time of assessment.

Another resident with Parkinson’s disease, anxiety, depression, chronic pain, and moderate cognitive impairment (BIMS 11/15) was care-planned as high risk for falls due to Parkinson’s disease, neuropathy, and dementia with impaired safety awareness. This resident had multiple unwitnessed falls in the room related to impaired safety awareness and attempts to self-transfer or reach for items. For one fall, a CNA Fall Investigation form, which should have included last interaction, items within reach, toileting plan, care plan, and areas for improvement, was not completed. Across three separate falls, ten of thirty-one post-fall assessments did not include updated VS, instead relying on VS taken several hours to more than a day earlier.

A third resident with left-sided hemiplegia, dementia, diabetes, mood disorder, and moderate cognitive impairment (BIMS 10/15) was at moderate risk for falls due to left-sided weakness and impaired safety awareness. This resident experienced two unwitnessed falls in the room on the same day while reaching for items. An intervention was added to have two reachers within reach in the room. However, three of ten post-fall assessments lacked updated VS, using earlier readings instead. During observation, the resident was in a wheelchair in the middle of the room with both reachers placed against walls (one by the bed and one on top of supplies near the TV), and the resident demonstrated inability to reach either device. The DON confirmed the reachers were not within reach and stated they should be within reach at all times.

A fourth resident with vascular dementia, diabetes, stroke, and moderate cognitive impairment (BIMS 10/15) was at moderate risk for falls due to weakness and dementia. This resident had an unwitnessed fall in the room and could not recall the event. An intervention for a reminder sign to call for assistance before getting up was added to the care plan. Three of ten post-fall assessments did not include updated VS, instead using VS taken several hours earlier. During observation, the resident was seated in the room and no reminder sign was present. The DON later observed the room and stated the sign had been hung near the calendar but must have been taken down or misplaced and was unsure how long it had been missing. Staff interviews showed inconsistent understanding of post-fall monitoring practices: one RN stated the practice was to check residents once or twice per shift without neurological checks, while an LPN stated the facility still did standard post-fall neurological checks with VS at each assessment, and the DON stated policy required assessment once per shift unless otherwise ordered, with additional provider notification for residents on anticoagulants.