F0657

E

Failure to Update Care Plans With Fall-Prevention Interventions After Recurrent Falls

St. Albans, Vermont Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and update comprehensive care plans with appropriate fall-prevention interventions following recurrent falls for two residents. For Resident #1, the care plan dated 10/17/24 and revised 2/12/26 identified the resident as at risk for falls related to decreased mobility, pain issues, cognitive deficits, and recent falls, including a recent fall with several fractures in both lower extremities. A provider note dated 1/16/26 documented a fall without injury when the resident attempted to self-transfer and lost balance, and the care plan entry for that date only stated the resident fell out of the wheelchair in the bedroom and would be monitored closely. A subsequent health status note on 2/5/26 described staff hearing a thud and finding the resident on the floor in front of the wheelchair, denying head injury, with pain consistent with baseline and stable vital and neuro checks.

Despite these recurrent falls from the wheelchair on 1/16/26 and 2/5/26, review of Resident #1’s care plan showed no added interventions specifically addressing prevention of falls from the wheelchair. This was inconsistent with the facility’s Comprehensive Care Plans policy, which requires measurable objectives, time frames, and documentation of alternative interventions as needed, as well as notification of qualified staff when changes are made. During interview, an LPN stated she did not know how to access the resident’s care plan until shown and confirmed there were no interventions implemented in the care plan to prevent the resident from falling from the wheelchair and no fall interventions added after the falls on 1/16/26 and 2/5/26. The DON confirmed that Resident #1’s care plan should have been updated with interventions for falls out of the wheelchair for those dates.

For Resident #2, the care plan dated 8/27/25 and revised 1/23/26 identified the resident as at risk for falls related to bilateral left knee amputation, decreased mobility/balance, and a history of falls, with a fall risk assessment score of 17/32 indicating fall risk. An incident note dated 1/11/26 documented the resident found on the floor, covered in feces, sitting on the bottom with back against the wall near the wheelchair, unable to give a credible account of the fall, with the fall mat undisturbed; the care plan noted the resident was found on the floor after attempting to self-transfer with no injury. Another incident note on 1/23/26 documented the resident found on the floor mat beside the bed, and a 2/3/26 note described the resident found sitting on the fall mat after reporting a fall scenario, with no known injuries. A 2/1/26 note documented an attempted self-transfer from bed to get a remote, during which an LNA intervened to prevent a head-first fall, resulting in two skin tears treated and neurovitals within normal limits. Review of Resident #2’s care plan showed no additional documented interventions added for the falls that occurred on 1/11/26 and 1/23/26, and the DON confirmed that interventions such as room change, rehab referral, and frequent checks were not reflected in the care plan.