F0689

G

Failure to Revise Fall-Prevention Care Plan After Repeated Wheelchair Falls

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and effective fall-prevention interventions for a cognitively impaired resident with Alzheimer’s disease, osteoarthritis of the knee, and muscle weakness, who was dependent on staff for ADLs and required a mechanical lift for transfers. Fall risk evaluations conducted on 12/30/25 and 1/13/26 identified the resident as at risk for falls. The facility’s fall policy required individualized fall-prevention strategies and ongoing monitoring and modification of interventions. The resident’s fall care plan included general interventions such as assessing for drugs that may cause falls, encouraging rest in bed when tired, involving the resident in activities as tolerated, and maintaining safety (call bell within reach, bed in lowest position, proper lighting, appropriate footwear). After a fall on [DATE] in which the resident was found on the floor with severe knee pain and sustained a head hematoma and large knee bruise, the only care plan update was to document the fall with injury and to “follow facility fall policy,” without adding specific new interventions.

The resident experienced subsequent falls on 1/16/26, 2/5/26, and 2/8/26, all occurring in the resident’s room and involving the wheelchair, including one fall while attempting to self-transfer. After the 1/16/26 fall, the care plan was updated only to add “will monitor closely,” with no timeframes or clarification of staff responsibilities, and no new interventions were added after the 2/5/26 fall despite the emerging pattern of wheelchair-related falls. On 2/8/26, staff responded to the resident’s screams and found the resident on the floor in front of the wheelchair, in acute distress with right leg pain, leading to hospital evaluation and diagnosis of bilateral displaced severe ankle fractures. Interviews revealed that an LPN did not know how to access the resident’s care plan and confirmed there were no specific interventions to prevent falls from the wheelchair and no interventions added after the 1/16/26 or 2/5/26 falls. The DON confirmed that increased supervision was not implemented, the resident remained on 2‑hour checks without formal increase in supervision, IDT notes were not in the record, and the only additional intervention (a sleep hygiene assessment) was not reflected in the care plan.