Failure to Implement and Communicate Effective Fall-Prevention Measures for High-Risk Residents
Summary
The deficiency involves the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and fall-prevention interventions for multiple residents at high risk for falls. The facility’s own fall incident log showed 42 falls in a two‑month period. For one resident with anxiety, restlessness, agitation, hemiplegia, and hemiparesis, functional assessments documented a need for substantial/maximal assistance with bed mobility and that transfers were not attempted due to medical or safety concerns, yet this resident experienced two falls within days. After the first fall, the resident reported trying to go to the bathroom, and the incident report identified confusion, gait imbalance, and incontinence as predisposing factors, with a winged mattress added as an intervention. After the second fall, the resident was found on the floor outside the floor mats with a head laceration requiring staples, and staff documented that the resident was always attempting to get out of bed. Despite this, the care plan only reflected bed‑related interventions (wing mattress, ultra‑low bed, floor mats) and did not include supervision details, and therapy staff were unaware of the recent falls and left the resident in a specialty wheelchair in the therapy gym with only line‑of‑sight supervision while the therapist’s back was turned. Another resident with seizures, lack of coordination, muscle wasting/atrophy, and a history of falling had multiple falls documented at the nurse’s station and in the room. The resident’s post‑fall risk assessment failed to include a history of falls and/or fracture in the past six months, which would have increased the fall risk score. Incident reports described the resident having a seizure and falling from a wheelchair at the nurse’s station with a head injury, later documentation at the hospital describing an abrasion and hematoma, and subsequent falls where the resident was found on the floor after attempting to go to another room, including a fall at the nurse’s station resulting in a laceration to the eyelid. The care plan identified the resident as high risk for falls with interventions such as staff assistance as needed and frequent rounding, but nursing staff interviewed only cited low bed, floor mats, soft helmet, and call light within reach, and did not mention frequent rounding. One LPN was not sure how the resident was to be transferred from bed to wheelchair, and another RN described the resident falling face down from a chair at the nurse’s station and sustaining a laceration to the eye, while documentation of the side of injury was inconsistent between facility and hospital records. A third resident with Parkinson’s disease, muscle wasting/atrophy, cognitive communication deficit, diabetes, chronic kidney disease, hypertension, benign prostatic hyperplasia, history of falling, and a recent right pelvic fracture with a non‑weight‑bearing order to the right leg was admitted after a fall at home. Functional assessments showed impairment in range of motion and a need for partial/moderate assistance with toileting and substantial/maximal assistance with transfers, with walking not attempted due to safety concerns. The fall risk assessment scored the resident as high risk, but the care plan did not include the non‑weight‑bearing status or the fractured pubis as a factor, and interventions were limited to low bed, call light and frequently used items within reach, and staff assistance as needed. The resident fell while trying to get to the bathroom, was found on the floor with a knot and redness on the head, and was sent to the hospital, where he was admitted for a fall and non‑acute pelvic fracture. The DON later confirmed that the non‑weight‑bearing order was not on the care plan, and a nurse reported that CNAs were transferring the resident with one‑person assist and that she was unsure of the resident’s weight‑bearing status or specific fall precautions. A fourth resident with legal blindness, multiple sclerosis, weakness, restlessness, and agitation had a care plan identifying high fall risk with floor mats as an intervention while in bed. The resident’s functional assessment showed a need for substantial/maximal assistance with rolling and that transfers were not attempted due to medical or safety concerns. During observation, the floor mat intended to protect the resident was folded and angled away from the bed, with an over‑bed table stored under the bed preventing proper placement of the mat. An LPN acknowledged that the mat should be bedside and that, in its current position, if the resident rolled out of bed between the beds, the resident would land on the floor. The ADON had to enter the room, move the over‑bed table, and reposition the mat correctly. Across these residents, staff interviews revealed lack of awareness of recent falls, uncertainty about transfer requirements and weight‑bearing status, incomplete or inaccurate fall risk assessments, and failure to implement or consistently apply care‑planned fall‑prevention interventions, including supervision and environmental safeguards, contrary to the facility’s fall prevention and management policy that requires identification of residents at risk, completion of fall risk evaluations, and modification of care plans after each fall.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unsafe Cord Placement and Failure to Follow Fall Interventions: A resident with cognitive impairment and wheelchair use had a TV power cord stretched tightly across the closet doorway, blocking access and creating an environmental hazard when staff had to lift the cord to open the closet. Another resident with severe cognitive impairment and a fall-risk care plan repeatedly ran barefoot in the hallway while staff observed but did not consistently provide planned interventions such as gripper socks, footwear, ambulation assistance, or redirection.
A resident with impaired cognition, cancer, non-Alzheimer's dementia, extensive ADL needs, and a fall history was identified as a high fall risk with care plan interventions including removing a movable bedside table. After a fall, the resident was found using the table as a walker, yet observations showed the table still placed beside the bed on multiple occasions, including when staff were present. Staff interviews confirmed they were unaware of the current fall prevention interventions and that the table remained at bedside for meals despite the care plan.
Failure to complete a restraint assessment before using a wheelchair alarm for a resident with muscle weakness, difficulty walking, repeated falls, and dementia. The care plan included the alarm as an intervention, but the record lacked an initial Restraint Evaluation, and the CNO confirmed the assessment had not been completed before the alarm was placed.
A resident with cognitive deficits, dementia, Alzheimer's disease, fracture, and repeated falls was dependent for toileting and care planned for an EZ stand with 2-person assist. During observed transfers, staff placed the harness and straps correctly, but the resident only rose to about 135 degrees and never came to a full stand, while staff remained by the bathroom door during privacy periods and continued the transfer despite the resident not standing fully. An RN stated the resident was expected to stand straight up with the EZ stand and that staff should sit the resident back down and try again if not.
A resident with Alzheimer's disease and dementia was found wandering in the parking lot after leaving the building unsupervised. A family member visiting another resident saw her looking into car windows and alerted staff, who were not aware she had exited until the report. Staff interviews showed the resident had been seen earlier eating in the dining room, but no one was actively looking for her or knew she had left the facility.
A resident with parkinsonism and Alzheimer's disease, severe cognitive impairment, and a fall history was pushed in her wheelchair without foot pedals and was not assisted when she called out for help. Nursing notes and staff interviews showed a CNA propelled the resident multiple times without foot pedals, including one instance where her socked foot hit the floor, and staff acknowledged that foot pedals should be used when pushing a resident.
Unsafe Cord Placement and Failure to Follow Fall Interventions
Penalty
Summary
The facility failed to ensure a television power cord was properly secured and maintained so it did not create an environmental accident hazard for R46. R46’s quarterly MDS identified moderate cognitive impairment, maximum assistance needed for dressing, grooming, and toileting hygiene, moderate assistance with transfers, and wheelchair use. During observation, R46 was in his room with the television mounted on the wall between the bathroom and closet, and the power cord ran across the closet doors and across the upper drawer of the dresser to a surge protector on top of the dresser. When R46 tried to open the closet doors, the cord was stretched tightly across the doorway and prevented the doors from opening fully unless the cord was lifted away. A later observation showed NA-D had to lift the cord above the closet door to open it and retrieve clothing. NA-D stated the cord had been positioned that way for about one year and could be dangerous if R46 pulled on it, and maintenance staff stated they were only notified that day that the television needed to be fixed. The facility also failed to ensure fall interventions were followed for R13, who had severe cognitive impairment with disorganized thinking and inattention, verbal behaviors toward others, and dependence on staff for footwear and partial to moderate assistance with dressing. R13’s care plan identified her as at risk for falls and included interventions such as ambulating with the resident, encouraging gripper socks, obtaining slip-on shoes, reducing noise, offering snacks, assisting her back to her room when running in the hallway, offering a wheelchair, and redirecting her to slow down. During observations, R13 repeatedly exited her room barefoot and ran through the hallway, including multiple times over an extended period, while staff observed but did not provide gripper socks or shoes, walk with her, redirect her to slow down, or offer other care-planned interventions. Staff interviews indicated they had difficulty redirecting her because she became agitated, and the DON stated the care plan should be followed to ensure safety.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement care planned interventions to prevent further falls for one resident who was reviewed for falls. The resident had moderate impaired cognition, diagnoses including cancer and non-Alzheimer's dementia, required extensive assistance with ADLs including toileting, transfers, and locomotion, and had a history of falls. The resident's care plan identified the resident as a high fall risk related to de-conditioning, cognitive deficits, and prior falls, and included interventions such as anti-rollbacks on the wheelchair, appropriate footwear, keeping a wheelchair behind the resident when ambulating, and removing the mobile bedside table from beside the bed. After a fall in which the resident was found on the floor by the room doorway with the mobile bedside table in the hallway next to him, the resident stated he had been using the table as a walker. Despite the care plan and post-fall assessment identifying removal of the mobile bedside table as an intervention, observations showed the movable bedside table still placed alongside the bed on multiple occasions, including when staff were present in the room. Staff interviews confirmed they were unaware of the current fall prevention interventions, acknowledged the table was movable, and stated it remained at the bedside to facilitate meals. The DON confirmed the table had been at the bedside and was removed only after the surveyor discussed it with staff.
Failure to complete restraint assessment before wheelchair alarm use
Penalty
Summary
The facility failed to complete a restraint assessment before implementing a wheelchair alarm for Resident #18. Resident #18 was admitted with multiple diagnoses including muscle weakness, difficulty walking, repeated falls, and dementia. The care plan for impaired mobility and fall risk, dated 3/8/26, included a wheelchair alarm as an intervention. A Bed Safety and Transfer Device Evaluation dated 4/28/26 documented that the bed/chair alarm did not restrict mobility, but the record did not include an initial Restraint Evaluation dated on or around 3/8/26 to identify the comprehensive evaluation of the chair alarm. On 7/9/26, the CNO stated that a Restraint Evaluation had not been completed prior to the chair alarm being placed for Resident #18.
Inadequate Supervision During EZ Stand Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for one resident during transfers with an EZ stand lift. The resident had cognitive deficits and was dependent for toileting, with diagnoses including Alzheimer's disease, dementia, fracture, and repeated falls. The care plan identified a moderate fall risk related to weakness and directed toileting with an EZ stand and 2-person assist. During observation, nursing assistants placed the harness, safety belt, straps, and loops appropriately and assisted the resident with the lift, but the resident stood only to approximately 135 degrees and never came to a full stand. On two observed transfers, staff remained by the bathroom door while the resident was given privacy, then re-entered to continue the transfer and complete care. In both observations, the resident never achieved a full standing position despite encouragement and repeated attempts. One nursing assistant stated the transfer was safe because two staff were assisting, while the RN case manager stated she expected the resident to stand straight up when transferred with the EZ stand and that staff should sit the resident back down and try again if the resident did not. The RN case manager was unaware of any concerns about the resident transferring safely with the EZ stand. Facility policy was requested but not provided.
Resident Left Unsupervised and Was Found Wandering in Parking Lot
Penalty
Summary
The facility failed to recognize that a cognitively impaired resident had left the building unsupervised and was wandering in the parking lot. The resident had diagnoses including Alzheimer's disease, dementia, and anxiety disorder, and records showed she had moderately impaired cognition, walked and transferred independently, and had no documented wandering behaviors during the MDS lookback period. Although an elopement evaluation had previously concluded she was not at risk for elopement, the care plan identified confusion, impaired cognition, and lack of awareness of safety needs. On the day of the event, a family member visiting another resident saw the resident outside in the parking lot looking into car windows and walking from car to car with a jacket and pocketbook on her arm. The family member stated the resident appeared to be looking for someone and was in the middle area of the parking lot before she reported it to staff. Nurse #3 was notified and went to check on the resident, who was then brought back inside the facility. Staff interviews showed they were not actively looking for the resident and did not know she had exited the facility unsupervised until the family member reported seeing her outside. Staff accounts indicated the resident had been seen earlier in the dining room eating, but no one was aware she had left the building. Nurse #2 and NA #1 both stated they were not aware the resident was missing until the report from the family member. The administrator stated the resident exited through the front entrance doors, but it was not known whether she pushed the button behind the receptionist desk or was let out by a visitor. The previous NP stated the resident needed someone with her if she was outside the facility and could have wandered away if left alone.
Failure to Respond to Help Requests and Use Foot Pedals During Wheelchair Transport
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for R25 when staff did not respond to her requests for help and did not provide foot pedals while propelling her wheelchair. R25 had diagnoses of parkinsonism and Alzheimer's disease, and her records documented severely impaired cognition, including a BIMS score of four on a quarterly MDS. Her care plan stated she was independent with locomotion in her manual wheelchair, but other documentation reflected a history of falls and need for staff assistance with wheelchair mobility. The care plan also lacked documentation regarding foot pedals. Nursing notes and staff interviews showed multiple instances in which R25 was pushed in her wheelchair without foot pedals. On one occasion, a CNA propelled her out of the restroom and her socked foot hit the floor when the wheelchair was pushed. On another occasion, R25 was seated in her wheelchair, holding onto the back of a recliner and calling out for help, while the CNA walked by her. The CNA later propelled R25 down the hallway without foot pedals and at one point pushed the chair and let it go. Staff interviews confirmed that residents should have foot pedals when staff are pushing them, and the CNA stated she should not push R25 without foot pedals.
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