F0689

G

Failure to Maintain Fall Prevention Interventions Resulting in Resident Fall and Head Laceration

College Station, Texas Survey Completed on 03-02-2026

Penalty

Fine: $19,135

Summary

The deficiency involves the facility’s failure to keep a resident’s environment as free of accident hazards as possible and to provide adequate supervision and assistive devices to prevent accidents. A male resident with severe cognitive impairment (BIMS score of 3), dementia, reduced mobility, repeated falls, gait and mobility abnormalities, history of TIA and cerebral infarction, and lack of coordination was care planned as being at risk for injury from falls. His comprehensive care plan, revised in January 2026, specified that he required a fall mat beside the bed whenever he was lying in bed and that his bed should be kept in the low position at night. The care plan also documented that he was dependent or required significant assistance for ADLs and transfers, used a wheelchair, and was totally dependent on staff for locomotion.

On the morning of 02/12/2026, the resident was found on the floor beside his bed with bleeding from his head and mouth. An activity note documented that staff were called to the room, found that he had fallen from bed onto the floor, and that he stated he had been trying to get up. Nursing documentation and hospital records showed that he sustained a laceration to the scalp requiring three staples and a laceration to the lower lip closed with skin glue. A weekly skin assessment recorded abrasions to the right side of the lip and inside the mouth, and a laceration on the top right side of the head with three staples, though no measurements were documented. A neuro assessment later that day showed vital signs within normal limits, confused but coherent verbal responses at his baseline, and no new neurological changes requiring physician notification.

Multiple staff interviews and observations established that the resident’s fall prevention interventions were not in place at the time of the fall. A CNA who discovered the resident on the floor around the beginning of the day shift reported that his bed was in a high position, he was not on a fall mat, and the fall mats were rolled up and leaning against the wall near the window, despite her understanding that he was a fall risk who was required to have his bed in low position with fall mats beside the bed whenever he was in bed. Another CNA who responded to the incident also stated that there were no floor mats beside the bed, that the mats were rolled up against the wall, and that the bed was in a high position. The LVN who assessed the resident after the fall confirmed that he was lying on the floor without fall mats beside the bed and that the bed was not in the lowest position, estimating it to be mid-position. The night-shift CNA who had put the resident to bed the evening before stated she did not see any fall mats in the room and was not aware he required them, although she acknowledged that the Kardex was available for CNAs to review resident care needs. Other CNAs interviewed stated that, prior to this incident, the resident was known as a fall risk who required fall mats and a low bed per the Kardex. The administrator stated that all staff were expected to follow care plan interventions and that nurses were responsible for ensuring CNAs followed residents’ care plans.