F0689

G

Failure to Prevent Fall and Head Injury in Known Fall-Risk Resident

West, Texas Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a resident’s environment free from accident hazards and to provide adequate supervision and fall interventions, resulting in a fall with head laceration and a trace subarachnoid hemorrhage. The resident was an adult male with diagnoses including metabolic encephalopathy, peripheral vascular disease, acute kidney injury, and diabetes. His most recent MDS showed a BIMS score of 14, indicating he was cognitively intact, with no functional limitation in lower extremity range of motion, and he required only set-up or clean-up assistance for transfers and sit-to-stand. His care plan identified an ADL self-care performance deficit related to mild cognitive impairment and metabolic encephalopathy, and documented that he required set-up to touching assistance with transfers by one staff member.

The resident had a documented history of multiple prior falls, including falls while attempting to self-transfer, falls in his room and restroom, and a fall with a head laceration that led to transfer to the hospital. His care plan for actual falls related to unsteady gait listed multiple fall events with dates and noted that he had a goal to resume usual activities without further incident. Interventions on the care plan included encouraging the resident to wear nonskid socks, ensuring adequate lighting, and using a fall mat at bedside if the resident allowed. Physician orders also included floor mats at bedside if the resident allowed, and a Morse Fall Scale assessment identified him as at moderate risk for falls.

On the day of the incident, the resident reported that he believed he had been asleep and fell out of bed, striking his head and causing bleeding, but he could not recall what he was doing before the fall or how it occurred. Staff interviews indicated that the CNA assigned to the hall was making rounds room to room and had been in the room next door to the resident when she saw what she initially thought were socks on the floor, then realized it was the resident’s feet. She found the resident on the floor near the doorway, alert and responsive, with blood noted by the bed. The LVN reported she had not been down the hall for about 30 minutes but knew the CNA was rounding; when called, she assessed the resident, noted a bleeding head wound, and observed blood on the remote hanging off the bed and on the floor by the head of the bed. The resident was later diagnosed at the hospital with a laceration to the back of the head requiring 12 staples and a trace subarachnoid hemorrhage of the anterior interhemispheric fissure. The facility’s fall prevention policy required evaluation of fall risk, routine visits to check on residents, use of bedside floor mats when appropriate, and documentation of interventions, but the resident’s repeated falls and the circumstances of this unwitnessed fall demonstrated that the environment and supervision were not sufficient to prevent this accident.

The resident expressed that he did not like the fall mat by his bed because it made wheelchair mobility more difficult, and family and staff interviews confirmed he frequently attempted to do things on his own and did not consistently use the call light. The DON and ADM stated that staff were expected to round on residents at least every two hours, with some staff reporting they rounded more frequently, such as every 30 minutes to an hour. Despite these stated practices and the resident’s known fall history and moderate fall risk, the fall occurred unwitnessed between staff checks, with the resident found on the floor by the door and evidence of blood near the bed and on the remote. The combination of the resident’s established fall risk, prior falls while self-transferring, care-planned need for assistance with transfers, and the unwitnessed nature of the fall with serious head injury formed the basis for the cited deficiency in providing an environment free from accident hazards and adequate supervision to prevent accidents.