F0689

G

Repeated Falls and Inadequate Individualized Fall-Prevention Measures Resulting in Head Laceration

Montrose, New York Survey Completed on 03-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and necessary devices to prevent accidents for a resident with Parkinson’s disease and a known history of falls. The resident had mild cognitive impairment, short-term memory deficits, impaired mobility related to Parkinson’s, and required partial to moderate assistance with toileting, hygiene, bathing, and other ADLs. Despite being identified as high risk for falls on multiple Fall Risk Assessments and having a care plan for falls initiated and periodically updated, the resident experienced eight falls over several months, including falls in their room, in the hallway, and while attempting to ambulate or reach for items. The resident’s care plan initially included general interventions such as gradual position changes, monitoring psychotropic medications, psychiatric consultation as needed, and later a fall risk identifier, but these measures did not prevent repeated falls.

Following specific fall events, documentation shows that the facility often implemented only short-term post-fall monitoring such as neuro checks and frequent checks for limited periods, without consistently revising the long-term fall prevention care plan to address the causes and circumstances of each new fall. After the fall on 10/18/2025, when the resident hit their head and required hospital evaluation, there was no documented evidence of updated interventions to the care plan. After the fall on 10/31/2025, the care plan note documented injuries and short-term monitoring, but again no documented long-term interventions to prevent additional falls. Subsequent falls on 01/02/2026 and 02/07/2026 similarly lacked documented revisions to the fall-related care plan, despite repeated confirmation that the resident remained at high risk for falls. Although hip protectors were provided and reminders to use the call bell were documented, there was no evidence of systematic adjustment of interventions in response to the pattern and circumstances of the falls.

The resident’s final documented in-facility fall on 03/17/2026 occurred in their room while they were ambulating and interacting with two CNAs, during which the resident refused to sit and then fell backward, striking their head on a nightstand and sustaining a scalp laceration requiring six stitches. Witness statements from the CNAs described the resident walking around the room, telling staff not to touch them, and then spinning around and falling. The physician later documented that the resident, who had a gait disorder, was walking with a walker and reaching for a wheelchair when they fell backward and hit their head. Interviews with the complainant and facility leadership revealed that there had not been meaningful care plan meetings with the resident and family to discuss fall risk and prevention, and that the DON was unsure what devices PT had recommended or whether environmental safety measures such as floor mats or a reacher had been assessed or implemented. Staff interviews indicated awareness that the resident was at high risk for falls and that frequent monitoring and prompt response to call bells were expected, but there was no clear specification of monitoring frequency or individualized fall-prevention strategies beyond general rounding and basic positioning measures. This pattern of repeated falls, limited care plan revision, and lack of documented individualized environmental or device-based interventions led to the resident sustaining actual harm from the head laceration.