F0689

D

Failure to Implement and Maintain Effective Fall-Prevention Measures for Two High-Risk Residents

Redford, Michigan Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain effective fall-prevention interventions and environmental safety measures for two residents with known fall risk and significant functional impairments. For one resident (R901), surveyors observed the individual lying in bed with severe muscle wasting, contracted lower extremities, and dependence on staff for all bed mobility and activities of daily living. The resident’s bed was positioned with one side against the wall, a floor mat on the opposite side, and a pillow placed under the bottom sheet on the right side that did not actually support the resident. The call light was found under the bedcovers on the wall side and later hanging over the headboard, not accessible to the resident. The urinary catheter leg anchor was not secured, and no low air loss or specialty mattress was in place despite a care plan intervention for a concave mattress with side bolsters that had been initiated and revised in January. The resident’s responsible party reported multiple pressure-related wounds and questioned how the resident, who had contracted legs and minimal ability to move, could have fallen from bed onto the floor.

Record review for R901 showed an actual fall documented on 01/10/26, with a progress note stating the resident was found lying on the floor mat near the bedside during morning rounds. The care plan documented that the resident had an actual fall and included interventions such as frequent repositioning in bed and use of a concave mattress. The Minimum Data Set indicated impaired cognition and total dependence on staff for hygiene, toileting, dressing, rolling in bed, and transfers. Despite these documented needs and planned interventions, surveyors repeatedly observed the resident over two days without the ordered specialty or low air loss mattress, without pillows or bolsters supporting the torso, and with the call light not positioned within reach. Additionally, an LPN reported that the call light system on the resident’s unit had not worked properly for more than six months, with no audible tone heard upon activation.

For the second resident (R903), the facility did not implement additional or modified fall-prevention interventions despite multiple falls and known cognitive and mobility issues. Progress notes documented that on 01/16/26 the resident was found sitting on the floor with knees bent, with a hematoma and laceration to the forehead and abrasions to the cheek. The resident was assisted back to a wheelchair and later sent to the ED for a CT scan at the granddaughter’s request. Staff interviews indicated that this resident was wheelchair-bound, unsteady, impulsive, often attempted to ambulate or transfer without assistance, and was non-compliant with directions. The DON and unit manager reported that the resident had severe cognitive deficits, wanted to be independent, was less directable, and had three falls in a short period, including one in the chapel and another in a common area, with staff suspecting a UTI during this time.

R903’s care plan identified the resident as at risk for falls due to weakness, gait imbalance, poor safety awareness, impulsivity, and transferring without assistance, with interventions such as ensuring wheelchair wheels were locked, appropriate footwear, a safe environment, bed brakes locked, call light in reach, Dycem to the wheelchair, supervision so whereabouts were known, and a floor mat when in bed. However, no new or revised fall-prevention interventions were documented between the initial fall and subsequent falls on or before 01/19/26. The activity aide who witnessed one fall in the chapel reported the resident suddenly slid out of a chair and did not recall seeing non-slip material in the wheelchair seat. Staff also reported that after the initial fall, the facility’s practice was to keep residents in-house unless they were on blood thinners or had a mental status change, and the unit manager confirmed that the resident was kept in common areas after one fall but continued to be impulsive and experienced another fall from the wheelchair later the same day. The facility’s own fall management guidelines stated that the interdisciplinary team would review and modify the plan of care to minimize repeat falls, but documentation showed no additional interventions were added for this resident prior to the later fall with a hip fracture identified at the hospital.