F0689

G

Failure to Implement Fall-Prevention Interventions and Supervision for a High-Risk Resident

Kalamazoo, Michigan Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement interventions for increased supervision and assistance for a resident assessed as high risk for falls, resulting in an unwitnessed fall with head laceration and subsequent hospitalization for SAH and SDH. The resident was admitted with diagnoses including sepsis, weakness, cognitive deficit, insomnia, and a history of repeated falls. A BIMS score of 4 indicated severe cognitive impairment. A fall risk assessment completed shortly after admission identified the resident as high risk for falls with a score of 24, noting intermittent confusion, recent hospitalization, and wheelchair confinement with disorientation; however, the mobility status documented on the assessment was not an accurate reflection of the resident’s actual status.

Despite the high fall risk assessment, there was no fall prevention care plan or care plan addressing the resident’s high risk for falls in place until after the resident experienced a fall and was discharged to the hospital. The ADL care plan initiated shortly after admission only addressed assistance with daily care needs related to general weakness and included an intervention for direct feeding assistance; other interventions, including those related to transfer assistance and fall risk, were not added until after the fall. The record did not document whether the resident was continent or incontinent or whether a toileting program was in place. Staff interviews confirmed that the baseline care plan developed within 24 hours of admission did not include high fall risk status, fall prevention interventions, or the level of assistance needed for transfers and ambulation, and that this information was not carried over to the CNA Kardex.

On the morning of the incident, a CNA found the resident on the bathroom floor in a puddle of blood and emesis, with a blood trail from the bed to the bathroom and bleeding from the head. The fall was unwitnessed, and the resident was unable to describe what had happened or localize pain. Nursing staff observed a head laceration and arranged for transfer to the hospital, where records documented a right scalp laceration and diagnoses of SAH and SDH after being found down at the facility. Interviews with CNAs and therapy staff indicated that the resident was unsteady, did not use the call light, walked on her own, and required at least one-person assistance for safe transfers and ambulation, but the CNAs were not aware she was a major fall risk because there were no fall-risk indicators in the room and the Kardex lacked this information. The facility’s fall policy required that residents at risk for falls be identified and individualized fall precautions implemented, including appropriate supervision and management of incontinence/toileting, but these measures were not implemented for this high-risk resident prior to the fall.

Additional information from interviews further supported that the resident’s high fall risk and need for assistance were known but not translated into care planning and supervision practices. The DON reported that nursing had assessed the resident as high risk for falls upon admission and therapy had determined she required at least one assist for transfers and ambulation, yet this was not documented in the care plan or Kardex until after the fall. The DON also stated that the care plan is supposed to carry over direct care needs to the Kardex, which CNAs rely on to determine resident needs, and acknowledged that the resident should have had frequent checks and should not have been ambulating alone. Family reported that the resident had multiple falls at home and did not understand she was unsafe to walk independently. Therapy evaluations documented impaired safety awareness, severely impaired decision-making, and the need for partial/moderate assistance with transfers and ambulation, reinforcing that the resident required supervision and assistance that were not implemented before the fall.

The facility’s written fall policy, "Fall Evaluation Safety Guideline," required completion of a fall risk evaluation, implementation of resident-specific interventions when risk is identified, and initiation and revision of a fall care plan with appropriate interventions such as environmental evaluation, applied supervision, and management of incontinence/toileting. In this case, although the resident was evaluated and identified as high risk for falls, the required individualized fall precautions and care plan interventions were not put into place prior to the unwitnessed fall. This lack of timely care planning, communication of transfer and ambulation needs to direct care staff, and implementation of increased supervision and assistance for a known high-risk resident led to the deficiency cited under the requirement to ensure the environment is free from accident hazards and that adequate supervision is provided to prevent accidents.