F0689

D

Failure to Follow Fall-Prevention Care Plan and Supervise High-Risk Resident in Dining Room

El Dorado, Kansas Survey Completed on 04-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe environment for a resident with a known high risk for falls, particularly in the dining room. The resident had diagnoses including Alzheimer’s disease, anxiety, atrial fibrillation, and muscle weakness, with a BIMS score of 8 indicating moderately impaired cognition. Assessments documented that the resident required partial staff assistance for eating and mobility, was dependent for transfers and toileting, did not ambulate, and had been identified as high risk for falls on multiple fall assessments. The care plan contained specific fall-prevention interventions, including ensuring non-slip footwear, use of a floor mat by the bed, not leaving the resident unattended in the dining room after meals, keeping the resident in the wheelchair rather than transferring to a dining chair for meals, use of an antithrust cushion with Dycem in the wheelchair, and removal of the Hoyer sling from the wheelchair after transfers.

Despite these identified risks and documented interventions, the resident experienced multiple falls in the dining room. A fall on 12/21 was documented after the resident had been one-on-one all afternoon due to attempts to stand and walk and expressing a desire to go home; staff later found the resident on the dining room floor. A subsequent fall on 03/11 occurred when another resident called for help and staff found the resident seated on the floor in front of the wheelchair; the investigation identified that the sling from the mechanical lift had not been removed after transfer, and this was determined to be the root cause of that fall. Another fall on 03/28 occurred when the resident was found lying face down on the floor with the wheelchair at her feet, and documentation noted that the resident needed to go to the bathroom after a meal and had not been offered toileting.

Observations and staff interviews further showed that the facility did not consistently follow the resident’s care plan interventions. On 04/06, the resident was observed being pushed to the dining room in a wheelchair with the sling still under her, contrary to the care plan directive to remove the sling after transfer. On 04/07, a CNA was observed leaving the sling partially under the resident in the wheelchair and looping the sling straps around the wheelchair handles after using the Hoyer lift. Staff, including a CNA and a licensed nurse, acknowledged that the resident was impulsive, had multiple falls, and required close observation. An administrative nurse stated that the resident should not have been left alone in the dining room because of her impulsivity and history of falls and that staff were expected to follow the care plan. The facility’s fall policy required review of the care plan and evaluation of the circumstances of falls to determine causes and implement appropriate interventions to prevent further falls, but the repeated falls and observed practices demonstrated that key care plan interventions were not consistently implemented.