Failure to Revise Fall-Prevention Interventions After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to keep residents free from accident hazards and to provide adequate supervision and interventions to prevent accidents, particularly falls, for two residents. One resident had a care plan identifying fall risk related to decreased cognition, poor safety awareness, and a need for encouragement to sit or rest, with four fall-prevention interventions dated 12/5/2025. On 1/4/26, progress notes documented that this resident was sleeping in a chair, leaning forward, and fell to the floor, striking the right frontal head and developing a quarter-sized bump on the right lateral forehead. Despite this fall, no new interventions were added to the care plan. Two days later, at 4:30 a.m. on 1/6/26, the bed alarm sounded and staff found the same resident sitting on the floor next to the bed with a quarter-sized abrasion on the left forehead, and again, the care plan showed no new interventions to prevent future falls. Another resident with diagnoses including unspecified dementia with behavioral disturbance, repeated falls, history of falling, weakness, and unsteadiness on feet had a care plan problem stating the resident was at risk for falling due to decreased safety awareness. Between 9/29/25 and 12/27/25, this resident sustained eight documented falls, including being found sitting on the floor next to a wheelchair in a former room, on the bathroom floor of a former room, on the floor next to the bed with a head injury and headache after attempting to get into bed, on the floor on knees and forehead in front of the wheelchair, falling forward out of the wheelchair, sitting naked on the floor outside the room after incontinence, losing balance and falling while walking out of another patient’s room, and rolling out of bed while attempting to get out of bed. Record review showed no documented new interventions added to the resident’s care plan after any of these falls. In an interview, the DON confirmed that there were no new interventions implemented after the falls for either resident and acknowledged that new interventions should have been attempted after each fall.
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