F0689

D

Failure to Analyze Falls, Implement Interventions, and Complete Post-Fall/Neuro Assessments

Omaha, Nebraska Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own falls management policy by not completing causal factor analyses, not implementing or documenting fall-prevention interventions, and not performing required post-fall and neurological assessments for multiple residents. For one resident with metabolic encephalopathy, repeated falls, muscle weakness, moderate cognitive impairment, and identified need for partial/moderate assistance with mobility and transfers, the record showed several falls over a short period. Progress notes for these falls documented basic assessments and vital signs but did not include causal factors for the falls or new interventions to prevent recurrence, except for resident education to use the call light and a transfer to the emergency department after the final fall. Neuro checks were only initiated after one of several unwitnessed falls, despite the facility’s policy requiring neuro checks after any unwitnessed fall or fall with possible head injury.

The same resident’s care plan identified risk factors such as weakness, limited mobility, new environment, medications with potential adverse reactions, confusion, and poor safety insight, and called for one-person assist with ambulation, transfers, and toileting, as well as routine visual rounding. However, observations showed staff did not enter the resident’s room for several hours overnight to check or change the resident, despite a requirement to check residents every two hours. Later, an LPN observed the resident independently getting out of bed, ambulating with a walker to the bathroom, and transferring on and off the toilet without assistance or supervision, contrary to the resident’s MDS and care plan requirements. The DON confirmed staff should have checked the resident every two hours, assisted with transfers, and supervised toilet transfers, and also confirmed that the care plan did not include interventions related to the resident’s multiple falls and that neuro checks were not started after the first unwitnessed fall as required.

Another resident with a right femur fracture from a fall had a fall data collection form identifying the air mattress as the root cause of the fall, with an initial intervention to change to a regular mattress. The care plan documented a new fall with right femur fracture and surgical aftercare, with an intervention of working with therapy post-surgery. Observations on two separate days showed this resident still lying on an air mattress. The DON confirmed that the internal fall investigation identified the air mattress as the reason for the fall, that the mattress had been changed to a regular mattress and then changed back to an air mattress at the resident’s request, and that there was no additional evidence of other interventions beyond therapy.

A third resident, admitted with hemiplegia and hemiparesis following a stroke and cognitively intact per MDS, experienced a witnessed non-injury fall during a self-transfer in the bathroom. The fall data collection documented the fall event, and progress notes included an entry at the time of the fall and a follow-up note the next day. However, review of the electronic health record, including progress notes, skilled services documentation, and scanned documents, revealed no further evidence of post-fall injury monitoring or documentation for the 72 hours following the fall. Nursing staff and the DON confirmed that residents should be monitored for 72 hours after a fall, with progress notes and vital signs every shift, and the DON confirmed there was no additional evidence that such assessments were completed for this resident. Across these residents, the facility did not ensure completion of causal factor analyses, implementation and documentation of fall-prevention interventions, or consistent post-fall and neurological assessments as required by policy.