Failure to Implement and Update Fall-Prevention Interventions After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement timely, measurable fall-prevention interventions in the care plan for a resident with a known high risk for falls. The resident had metabolic encephalopathy, dementia, and glioblastoma, with severely impaired cognition (BIMS score of 5) and required maximal assistance with toileting and transfers. On admission, the resident was identified as high risk for falls, with care plan interventions including ensuring the call light was within reach and use of appropriate footwear (brown leather shoes and non-skid socks) when ambulating. The resident had a history of a fall prior to admission and sustained an abrasion to the mid back after a fall on 12/19/2025. A physician order directed daily aspirin therapy. On 1/7/2026, the resident was found on the floor in a prone position in the room, with no visible injury and denial of pain, and the incident report directed that the resident care plan be updated to ensure non-skid socks were used every shift. A nursing note documented that the resident was wearing regular socks at the time of this fall, had hit the head, and was transferred to the hospital. On 1/19/2026, the resident was again found on the floor, reported hitting the head and vomiting, and was transferred to the hospital; an abrasion to the left ankle was noted. The care plan was updated only to reflect the hospital transfer, neurological checks, and treatment of the abrasion, and record review did not identify any new fall-prevention interventions after this fall or after the resident’s readmission. Interviews with the DNS and ADNS confirmed that the resident was supposed to wear non-skid socks, that staff did not follow the care plan at the time of the 1/7/2026 fall, that the care plan was updated with a repeat intervention regarding non-skid socks, and that no new interventions were documented after the 1/19/2026 fall, despite facility policy directing that the care plan be updated with appropriate interventions after a fall.
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