F0689

D

Failure to Implement Care-Planned Fall and Hazard Controls for High-Risk Resident

Stow, Ohio Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and maintain care-planned fall and accident-hazard interventions for a resident identified as being at risk for falls and injury. The resident was admitted with multiple diagnoses including unspecified dementia, quadriplegia, delusional disorders, early-onset Alzheimer’s disease, anxiety disorder, major depressive disorder, and epilepsy. On admission, the nursing evaluation identified the resident as at risk for falls, and the care plan documented fall risk related to impaired cognition and decreased safety awareness, with goals to reduce injury risk. Interventions included ensuring the room was free from accident hazards, placing a floor mat next to the bed, and later revising this to a mattress on the floor at bedside. The care plan also documented behavioral issues such as verbal aggression, yelling, throwing legs out of bed, resisting care, socially disruptive and attention-seeking behaviors, including a history of yelling fire and pretending to have seizures, with interventions to approach calmly and re-approach if agitated.

The resident’s care plan further identified an ADL self-care performance deficit related to quadriplegia, dementia, fluctuating ADLs, Alzheimer’s disease, and cognitive impairment, with documentation that the resident required one-person assistance for ADLs and a two-person assist with a mechanical lift for transfers. The MDS assessment indicated the resident was cognitively intact, had no impairment of upper and lower extremities, and was dependent for rolling in bed and transfers. Despite being care planned as dependent for mobility and at risk for falls, multiple interviews and observations established that the resident was able at times to move, scoot to the edge of the bed, and push herself off the bed. Staff, the POA, and the NP all reported that the resident could and did intentionally push or throw herself from the bed, sometimes to gain attention, and that she had a history of similar behaviors at a previous facility. The facility’s fall protocol required assessment of history of falls, cognitive/behavioral symptoms, mobility, and development and implementation of a plan of care to reduce falls and minimize injury.

The incident underlying the deficiency included an unwitnessed fall in which the resident was found on the floor next to the bed after reportedly throwing herself out of bed, with a hematoma near the left eye and an active nosebleed, requiring EMS transport to the hospital. At the time of this fall, the resident had a fall mat on the floor and a tube feeding pole with a feeding machine next to the bed, and staff reported the resident might have hit her head on the pole. Subsequent observations showed the resident with bruising and steri-strips on her forehead, and later lying in bed leaning over the side with an oxygen concentrator, wastebasket, and bedside table positioned near her head. A CNA immediately identified and removed these items as accident hazards, acknowledging the resident was a fall risk who could hit her head on them if she fell. The DON later acknowledged the resident probably hit the cement floor when she rolled off the bed. These findings demonstrate that the care-planned interventions to keep the room free of accident hazards and to provide adequate environmental protection (such as appropriate placement of mattresses and removal of hazardous equipment and furniture near the bed) were not consistently implemented, resulting in a failure to ensure a hazard-free area and adequate supervision to prevent accidents for this resident.

Additional interviews reinforced that the resident frequently reached over the side of the bed, grabbed and pulled on the floor mat, and pulled on nearby equipment such as the tube feeding pole. Staff, including the RN, CNA, NP, and DON, described the resident’s fluctuating physical abilities and behavioral components, including faked seizures, reports of chest pain, and self-propelling off the bed. Despite this known pattern and the care plan directive to keep the environment free of accident hazards and to use protective measures at bedside, the resident continued to have accessible objects and equipment within striking distance of her head while in bed. The facility’s failure to consistently remove or reposition these hazards and to fully implement the individualized fall and behavior-related interventions as care planned led to the cited deficiency for not ensuring the area was free from accident hazards and not providing adequate supervision to prevent accidents.