F0689

G

Failure to Analyze and Implement Effective Fall-Prevention Measures for High-Risk Resident

Edgerton, Wisconsin Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a high fall‑risk resident with severe cognitive impairment and multiple comorbidities. The resident had diagnoses including paranoid schizophrenia, severe dementia with mood disturbance, unsteadiness on feet, hip pain post fall, muscle wasting, delusional disorder, PTSD, CKD, and Type 2 diabetes. The resident’s MDS showed a BIMS score of 2/15, indicating severe cognitive impairment, frequent bladder incontinence, wheelchair use, and a need for partial to maximum assistance with all ADLs. John Hopkins Fall Assessment scores consistently placed the resident at high fall risk. The facility’s fall policy required timely cause identification, ongoing assessment, and monitoring of interventions, but this was not consistently carried out.

Over several months, the resident experienced numerous unwitnessed and witnessed falls in her room, bathroom, and peers’ rooms, including multiple falls from or near the bed and several falls related to toileting or incontinence. Incident reports repeatedly documented that no root cause was identified for many of these falls, and in several cases no new interventions were implemented despite recurrent patterns, such as falls while attempting to toilet, falls from bed, and sliding from the wheelchair. One fall while the resident was making her bed led to hospital evaluation and identification of multiple acute left rib fractures. The care plan contained numerous fall‑related approaches, including scheduled toileting, environmental adaptations, use of a low bed, scoop mattress, wheelchair with auto‑lock brakes, gripper socks, floor gripper strips, distraction and increased supervision with restlessness, and staff making the bed in the morning. However, the care plan also contained generic or incomplete elements (e.g., “Resident at risk for falling r/t ________” left blank) and interventions of questionable effectiveness for this resident’s cognition, such as a “call don’t fall” sign.

Staff interviews and observations showed that care‑planned interventions were not consistently implemented or clearly communicated. On observation, the resident was seen in a wide low wheelchair, wearing gripper socks, but had slid down in the seat, and her bed was stripped and not made. CNAs gave differing descriptions of the resident’s fall interventions, with some citing items such as Dycem in the wheelchair and keeping the resident near the nurse’s station, while others were unaware of Dycem or stated the resident did not have it. When surveyed, staff could not locate Dycem in the resident’s room, despite therapy indicating the resident was supposed to have Dycem under the wheelchair cushion and that it needed weekly replacement due to the resident’s tendency to remove it. Agency staff reported no specific education on fall interventions and relied on the electronic care plan, which did not clearly include all needed interventions such as Dycem. The DON acknowledged uncertainty about when root cause analyses using the “5 Whys” were started, had not yet reviewed this resident’s care plan, and agreed that some interventions (e.g., a call‑don’t‑fall sign) were not appropriate for the resident’s cognitive status and that Dycem should have been on the care plan. Overall, the facility did not complete thorough root cause analyses for repeated falls and did not ensure that care‑planned fall interventions were appropriate, updated, and consistently in place, resulting in multiple falls, including one with major injury.