F689 Falls Citations – What Surveyors Saw, Why They Tag, and How to Prepare
Introduction
Falls remain the single most-cited accident hazard in nursing homes, and Tag F689 (Accident Hazards/Supervision) dominates recent survey cycles. During the last six-month window reviewed here (February – May 2025), state agencies issued dozens of F689 deficiencies for falls, often coupled with significant monetary penalties (G - F0689 - IL) (G - F0689 - CO) . CMS’ Accidents Critical Element Pathway underscores why: surveyors must establish that residents are free of avoidable accident hazards and receive “adequate supervision to prevent accidents” [ref. 1001] .
Most common root causes of falls citations
Below is a frequency-based distillation of what surveyors documented. Each bullet begins with the situation they most often found, followed by a short “snapshot” from individual statements of deficiency so you can picture the issue.
Interventions not updated after a fall (or updated but never implemented)
- • Resident sustained two unwitnessed falls, yet the care plan still listed only the generic admit interventions; no individualized changes were added after either event (D - F0689 - IL) .
- • Four residents fell repeatedly — two with major injuries — and the facility “failed to add new interventions or revise the plan of care” after each episode (H - F0689 - NE) .
- • In multiple states, surveyors cited the repetition of the same generic orders (e.g., “encourage call light”) even when the resident could not cognitively use a call light (E - F0689 - IL) .
Interventions listed, but staff did not carry them out
- • Residents with 23 and 34 falls respectively were supposed to have call lights in reach, non-skid footwear, floor mats and Dycem on chair seats; surveyors repeatedly found these items missing while residents were left unattended (D - F0689 - IN) .
- • A resident’s wheelchair required anti-tippers; surveyors observed the chair without them, and staff stated the parts were “on back order” (G - F0689 - IN) .
- • Fall mats ordered for both bed sides were simply not present at the bedside during observation (D - F0689 - IL) .
Supervision lapses & staffing gaps
- • A cognitively impaired resident was supposed to stay in a common area; both falls occurred when staffing was below normal and the resident was unsupervised, leading to head injuries (D - F0689 - IL) .
- • Facility investigations showed falls happened while staff were on break and “there was insufficient staff to monitor residents adequately” (G - F0689 - IL) .
- • CNA attempted a one-person transfer despite a two-person requirement, resulting in yet another fall (D - F0689 - IL) .
Documentation & communication failures
- • Many falls lacked an incident report, 72-hour follow-up, physician notification or IDT note, leaving care teams unaware of circumstances or needed changes (D - F0689 - IN) (D - F0689 - IA) .
- • One unwitnessed fall with a laceration met state reporting criteria, but administration did not report because they “did not consider the bleeding significant” (E - F0689 - CA) .
- • Quarterly MDS coded “no falls” even though a progress note documented a bed fall in that look-back period (D - F0641 - NC) .
Inadequate root-cause analysis / repetitive fixes
- • After six similar self-transfer falls, surveyors noted interventions were simply duplicated (e.g., “educate resident”) without exploring the driving cause such as orthostatic hypotension or equipment placement (E - F0689 - IL) .
Missing or delayed clinical assessments
- • Policy required a post-fall assessment, but an LVN did not complete it until the next shift, leaving the resident without evaluation of new pain and twisted knee (D - F0689 - TX) .
- • Seventeen falls over nine months, yet staff could not show any formal reassessment of medications or mobility status until surveyors asked (G - F0689 - CO) .
Penalties
CMS imposes civil money penalties (CMP) and/or payment denials at the survey level. While the dollar amounts below cover the entire inspection cycle (not solely F689), they illustrate the financial exposure linked to serious fall citations.
| State | Tag(s) cited at G or higher | CMP ($) | Denial of Payment Days | Reference |
|---|---|---|---|---|
| IL | F689 (G) | 176,800 | 43 days | (G - F0689 - IL) |
| CO | F689 (G) | 20,090 | – | (G - F0689 - CO) |
| CO | F689 (G) | 26,680 | – | (G - F0689 - CO) |
No other reviewed statements listed CMPs or payment denials.
Compliance expectations & survey focus
Surveyors follow the CMS-20127 Accidents Critical Element Pathway when investigating falls. Key points operators should be ready to demonstrate include:
- Real-time observation of care-planned interventions – Teams will watch whether staff actually keep call lights within reach, provide transfer assistance, and place mats or alarms as ordered [ref. 1002] .
- Resident & environment factors – Inspectors look for slippery floors, poor lighting, bed-rail gaps, and other hazards; they also assess if residents are rummaging, exit-seeking, or exhibiting behaviors that require closer monitoring [ref. 1006] .
- Timely response to resident needs – The Pathway specifically asks whether staff respond to toileting requests and other calls for help, a frequent precipitant of falls in the deficiencies above [ref. 1003] .
- Post-fall investigation and care-plan revision – Records must show assessment of injury, identification of root causes, and documentation of new or revised interventions. Surveyors will verify whether “the care plan has been reviewed, revised, and evaluated for effectiveness” after an event [ref. 1004] .
- Accuracy of MDS coding – If J1900 fall items do not match documented events, surveyors are directed to cite F641 (Accurate Assessments) [ref. 1005] – mirroring the deficiency found in North Carolina (D - F0641 - NC) .
- Policy adherence – Teams may pull facility policies on fall prevention, bed rail use, staffing competencies, etc., and compare them to practice. Competency gaps, such as missing annual skills checks on fall-prevention techniques, are subject to F726 (Nursing Competency) (E - F0726 - CA) .
What documentation helps? Interdisciplinary post-fall huddles, root-cause tools, timely physician/representative notifications, and evidence that added interventions were cross-checked for availability (e.g., mats not on back order) all speak directly to these Pathway probes.
Conclusion
The common thread across recent fall citations is not the absence of ideas for prevention but the reliability of execution—failure to update, communicate, and stick to agreed-upon interventions. Surveyors will triangulate observations, records, and staff interviews to test that loop. Operators should audit whether every fall triggers a documented assessment, an immediate practical change, and direct staff education, then confirm via observation that those changes remain in place.
Keeping that closed-loop system tight is the surest way to reduce both fall frequency and F689 exposure in upcoming surveys.
Failure to Update Fall Interventions After Resident Falls
Penalty
Summary
A resident with multiple medical conditions, including muscle weakness, unsteadiness, reduced mobility, cellulitis, end stage renal disease, and a need for assistance with personal care, was admitted to the facility and identified as a high fall risk based on an initial Fall Risk Evaluation. Despite this high risk, the resident experienced two falls: one unwitnessed fall in her room and a second witnessed fall while transferring into bed. Following both incidents, the resident's Fall Risk Care Plan, which initially included only standard admitting interventions, was not updated to reflect the new falls or to add individualized interventions. The facility's Fall Prevention policy requires that safety interventions be added to the care plan for residents at risk for falls and that interventions be individualized. However, no changes or additions were made to the care plan after either fall, as confirmed by record review and staff interview.
Failure to Implement and Document Fall Prevention Protocols for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls were adequately supervised and protected from accident hazards, as evidenced by repeated failures to follow fall protocols, update care plans, and implement or maintain fall prevention interventions. Both residents had extensive histories of falls, with one resident experiencing 23 falls and the other 34 falls within a year. Despite documented high fall risk and multiple interventions listed in their care plans, there were numerous instances where interventions were not in place, such as call lights not being within reach, lack of non-skid footwear, and absence of required safety equipment like dycem or non-skid strips. Observations also revealed that residents were left unattended in their rooms, contrary to care plan instructions. The clinical records for both residents showed significant gaps in documentation and follow-through after falls. Many falls lacked Interdisciplinary Team (IDT) notes, timely updates to care plans with new interventions, and completion of fall risk assessments. In several cases, there was no evidence that the physician or responsible party was notified after a fall, and some falls were only referenced in 72-hour charting notes without details on the circumstances or follow-up. Additionally, some interventions added to care plans after IDT reviews were not observed to be implemented during surveyor observations. Both residents had complex medical histories, including dementia, muscle weakness, repeated falls, and other comorbidities that increased their vulnerability. Despite these risks, the facility did not consistently anticipate or meet their needs, failed to ensure prompt response to call lights, and did not always provide appropriate supervision or assistance with toileting and transfers. The lack of consistent documentation, communication, and implementation of fall prevention strategies contributed to ongoing falls and injuries for these residents.
Failure to Implement and Communicate Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement fall prevention interventions for two residents with known high fall risk, resulting in repeated falls and injury. One resident, with diagnoses including dementia, repeated falls, and severe cognitive impairment, experienced multiple falls over a period of time. Despite a care plan outlining numerous fall prevention interventions such as safety checks, anti-tippers for the wheelchair, non-skid footwear, and floor mats, these interventions were inconsistently implemented. After each fall, there was a lack of immediate new interventions to prevent further incidents, and required equipment such as anti-tippers and floor mats were often missing or on backorder. The resident sustained injuries including a left ankle fracture and a gash to the face, with documentation showing that staff and interdisciplinary team meetings did not result in timely or effective changes to the care plan or its implementation. Another resident, also with severe cognitive impairment and multiple comorbidities, was similarly identified as a high fall risk. The care plan for this resident included interventions such as anti-rollbacks for the wheelchair, floor mats, and non-skid strips. However, observations revealed that these interventions were not in place at the time of survey, and the resident experienced several falls, often found on the floor without the prescribed safety equipment. Staff interviews indicated confusion about who was responsible for implementing new interventions, and communication about fall interventions was inconsistent. Maintenance was sometimes responsible for installing equipment, but there was no clear process to ensure timely implementation. Throughout the report, staff interviews and observations highlighted a lack of awareness and understanding of the residents' fall interventions among CNAs, LPNs, and other staff. Communication about changes to care plans and interventions was primarily verbal during shift changes or huddles, and documentation was not always updated promptly. The facility's failure to ensure that fall prevention interventions were consistently implemented and that staff were adequately informed and trained contributed directly to repeated falls and injuries for residents at high risk.
Failure to Implement Fall Prevention Interventions After Resident Falls
Penalty
Summary
The facility failed to develop and implement appropriate interventions to prevent additional falls for four residents, resulting in two residents sustaining major injuries from subsequent falls. Facility policy required that after a resident fall, appropriate interventions should be recorded in the medical record, and that neglect, defined as failure to provide necessary care to avoid harm, should be reported to the state agency. However, there was no evidence that interventions were added or that serious injuries were reported as required. One resident with dementia, repeated falls, and a broken ankle experienced two unwitnessed falls within a short period, the second resulting in a fractured pelvis and subsequent hip replacement. Despite these incidents, no new interventions were implemented in the care plan following the falls. Another resident with severe cognitive impairment and a history of wandering and falls had multiple unwitnessed falls, including one resulting in a head hematoma. The care plan listed several interventions, but there was no evidence that new interventions were developed or implemented after the falls, and some interventions, such as encouraging use of the call light, were not appropriate for the resident's cognitive status. A third resident with encephalopathy, diabetes, and dementia had multiple falls, including one that resulted in a subdural hematoma and subarachnoid hemorrhage requiring hospitalization. No new fall interventions were added to the care plan after these incidents. A fourth resident with paranoid schizophrenia, heart failure, and dementia had two unwitnessed falls, one resulting in hospital evaluation for possible head injury, but again, no new interventions were added to the care plan. Interviews with the DON confirmed that interventions were not implemented following these falls, despite the expectation that they should have been.
Failure to Ensure Staff Competency in Fall Prevention Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed and demonstrated the necessary competencies in fall prevention, as evidenced by the lack of documented competency checks for all seven sampled nursing staff within the past year. Despite a high incidence of falls—42 occurring over a six-week period—there was no evidence that staff had been evaluated for their ability to implement fall prevention interventions. An in-service on fall prevention was held, but not all staff attended, and there was no follow-up to assess whether those who attended had achieved competency. The Director of Staff Development acknowledged that competency testing was not conducted after the in-service, and the facility could not provide any policy or procedure for staff competency assessment. This deficiency directly contributed to an incident in which a resident, who had involuntary tremors and required assistance with transfers, experienced an unwitnessed fall in the bathroom. The resident sustained a right intertrochanteric hip fracture, resulting in pain, decreased mobility, and a week-long hospitalization. At the time of the fall, the resident did not have fall prevention interventions in place, and staff were unsure how the resident ended up in the bathroom alone. Interviews confirmed that some staff had not attended the fall prevention in-service, and there was no documentation verifying staff competency in this critical area.
Inadequate Supervision Leads to Multiple Falls in High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate measures to prevent falls for three residents identified as high risk for falls. Resident 1, who was admitted with multiple health issues including alcoholic cirrhosis and dementia, experienced three unwitnessed falls in February, resulting in lacerations that required medical attention. Despite being identified as high risk for falls, Resident 1 was not under strict supervision, and staff failed to monitor the resident adequately, leading to falls that occurred without staff presence. Resident 2, admitted with chronic kidney disease and dementia, also experienced two unwitnessed falls in March, both resulting in injuries that required hospital visits. The facility's investigation revealed that the falls occurred during times when staff were on break, and there was insufficient staff to monitor residents adequately. The lack of supervision and failure to ensure staff coverage during breaks contributed to the incidents. Resident 3, with a history of hydrocephalus and cerebral infarction, had two falls, one in February and another in March, both resulting in injuries. The facility's investigation indicated that the falls occurred due to inadequate supervision and failure to assist the resident with repositioning. The physician confirmed that all three residents would benefit from close supervision to prevent falls, highlighting the facility's failure to implement necessary safety measures and supervision for high-risk residents.
Inadequate Fall Prevention and Supervision
Penalty
Summary
The facility failed to ensure accurate fall risk assessments and implement preventive interventions for two residents, leading to multiple falls and injuries. Resident 5, diagnosed with Alzheimer's disease and severe cognitive impairment, experienced several falls, including one resulting in an intracranial hemorrhage and traumatic head injury requiring staples. Despite being identified as at risk for falls, the resident's care plan was not updated following a significant fall incident, and interventions were not revised to prevent further falls. Resident 2, with a history of dementia and hemiplegia, also experienced multiple falls, including one that resulted in a head laceration requiring sutures. The resident's fall risk assessment was inaccurately scored, failing to account for hypotension and impaired memory, which would have indicated a higher risk. The care plan included interventions such as call light placement and regular rounding, but these were not effectively implemented, as evidenced by the call light being out of reach during an observation. The facility's management of falls policy requires comprehensive assessments and timely updates to care plans to address fall risks. However, the facility did not adhere to these protocols, resulting in inadequate supervision and failure to prevent accidents. The lack of appropriate interventions and supervision contributed to the residents' injuries and highlighted deficiencies in the facility's fall prevention practices.
Failure to Implement Fall Prevention Interventions for Residents
Penalty
Summary
The facility failed to implement effective interventions to prevent future falls or accidents for two residents, leading to repeated incidents. Resident 93, who had a history of falls, was admitted to the facility after repeated falls at her previous residence. Despite multiple falls within the facility, including one that resulted in a laceration requiring stitches, the facility did not implement new interventions beyond reminders to use the call bell and placing a sign in her room. The resident continued to experience falls, including incidents where she was found on the floor after attempting to transfer herself, indicating a lack of adequate supervision and intervention. Similarly, Resident 110 experienced a fall on March 1, 2025, but the facility did not implement any new fall prevention interventions until after a subsequent fall on March 3, 2025. The facility's plan of care for Resident 110 only included new interventions such as fall mats, a low bed, and a toileting program after the second fall. The Director of Nursing confirmed the absence of new interventions following the initial fall, highlighting a deficiency in the facility's response to fall incidents.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement and maintain fall prevention interventions for a resident with multiple risk factors, including dementia, agitation, delusional disorders, impaired decision-making, and frequent incontinence. The resident's care plan and bedside Kardex included several fall prevention measures such as visible signage, hourly toileting, non-slip strips in key areas, 15-minute safety checks, and assistance with transfers. Despite these documented interventions, observations and record reviews revealed that many of these measures were not in place or not consistently implemented. For example, non-slip strips were missing from the bathroom and recliner, the 'Call Don't Fall' sign was not visible, and non-slip material was absent from the wheelchair and recliner seats. Additionally, the resident's room was not moved closer to the nurse's station as planned, and required safety checks and hourly toileting were not documented or observed during the survey period. The resident experienced multiple falls over a three-month period, with documented incidents occurring in various locations such as in front of the recliner and in the bathroom. Progress notes indicated that the resident often attempted to move independently, including trying to use the toilet or brush teeth, which led to falls. Staff interviews confirmed that required 15-minute safety checks were not accurately documented or performed, and that interventions such as non-slip strips and materials were not consistently maintained. The resident also had a change in condition, including pitting edema and a diagnosis of hyponatremia, which was not fully addressed due to a missed blood test order that was neither completed nor followed up with the provider. Facility policy required thorough investigation of all falls, evaluation for changes in condition, provider notification, and implementation of new interventions as needed. However, the facility did not ensure that these protocols were followed, as evidenced by the lack of documentation, incomplete implementation of care plan interventions, and failure to complete ordered diagnostic tests. These lapses contributed to the resident's repeated falls and unaddressed changes in medical condition.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to adequately conduct a fall follow-up and implement necessary interventions for a resident identified as being at risk for falls. The resident, who was severely cognitively impaired and had a history of falls, experienced two falls within a short period. The first fall occurred when the resident was startled by an alarm, resulting in a trip to the emergency room for pain evaluation. The second fall was unwitnessed and occurred when the resident attempted to get out of bed, which was in a high position, leading to injuries that required sutures. Despite these incidents, the resident's care plan was not updated with new interventions to prevent future falls. The facility's policy on fall prevention required a post-fall assessment, incident report, and care plan review and update, none of which were fully completed following the falls. The interdisciplinary team assessment also failed to document additional interventions after the second fall, indicating a lack of comprehensive follow-up and preventive measures.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to ensure effective fall interventions were in place and followed, resulting in multiple falls for a resident. The resident, a female with multiple diagnoses including congestive heart failure, respiratory failure, Parkinson's disease, dementia, and lack of coordination, experienced three falls during transfers on 11/26/2024, 1/15/2025, and 2/16/2025. Each fall occurred while the resident was being transferred by a single Certified Nursing Assistant (CNA), despite a recommendation for two-person assistance after the second fall. The deficiency was highlighted by the incident on 2/16/2025, where the CNA was unaware of the two-person assistance requirement and attempted to transfer the resident alone, resulting in another fall. The Director of Nursing confirmed that the recommendation for two-person assistance was made after the fall on 1/15/2025, but it was not effectively communicated to all staff. The facility's Fall Prevention Protocol requires a review of the resident's care plan and consideration of new interventions after a fall, which was not adequately implemented in this case.
Failure to Prevent Repeated Falls and Inadequate Supervision
Penalty
Summary
The facility failed to implement effective interventions and provide adequate nursing supervision to prevent accidents and injuries from falls for a resident with a known history of repeated falls. Over a three-month period, the resident experienced thirteen falls, including an unwitnessed fall that resulted in a fracture to the left hand. Despite the resident's identified risk for falls, the care plan interventions were often delayed or insufficient, with some interventions not implemented until after further assessment or review by other disciplines, such as medication reviews or physical therapy evaluations. In several instances, the facility did not complete required incident reports or root cause analyses following falls or other significant incidents. The resident's clinical records indicated no cognitive impairment, but diagnoses included non-traumatic brain dysfunction, non-Alzheimer's dementia, and hallucinations. The resident was independent in most mobility tasks but required supervision for toileting and was frequently incontinent of urine. The incident reports and progress notes documented multiple unwitnessed falls in various locations, including the resident's room, hallway, and bathroom. Interventions such as encouraging the use of gripper socks, reviewing medications, and replacing furniture were inconsistently applied, and in some cases, no immediate interventions were put in place following incidents. Staff interviews revealed inconsistencies in the implementation and documentation of frequent checks and supervision, particularly regarding the resident's wandering behavior and entry into other residents' rooms. The facility's policy required all accidents and incidents to be reported, investigated, and reviewed through the QAPI process, with specific procedures for completing incident reports and root cause analyses. However, the facility failed to adhere to these policies in several instances, as evidenced by missing incident reports and delayed or inadequate interventions following repeated falls and other incidents involving the resident.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to develop and implement a resident-centered fall prevention care plan for three residents, leading to multiple falls and injuries. Resident 1, who had a history of falls and was at high risk due to conditions such as Parkinson's disease and atrial fibrillation, experienced three falls. The facility did not consistently monitor Resident 1 for post-fall injuries, update their care plan in a timely manner, or ensure that interventions were communicated to staff. After the third fall, Resident 1 was found to have a hip fracture and was over-sedated due to psychotropic medications. Resident 8, who had moderate cognition problems and required assistance for activities of daily living, experienced two falls in one night. The facility's investigation into these falls was incomplete, lacking details about the circumstances and necessary interventions. The care plan was not updated with timely interventions, and there was no consistent post-fall monitoring or documentation of physician notification. Resident 11, who had cognition problems and required assistance with activities of daily living, fell from their bed. The facility did not document consistent post-fall monitoring or notify the physician and responsible party. The care plan interventions were not effectively communicated to staff, as evidenced by the lack of implementation of specific interventions such as placing the bed in the lowest position and against the wall.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and effective fall interventions for two residents, leading to multiple falls and injuries. Resident #7, diagnosed with unspecified dementia, a history of falling, and muscle wasting, experienced 17 falls between June 2024 and March 2025. Despite the implementation of some interventions, such as fall mats and keeping the bed in a low position, the facility did not consistently update the care plan with new interventions after each fall. The facility also failed to identify the root cause of the falls, resulting in two incidents that required hospital transportation for treatment of injuries. Resident #4, with diagnoses including left-sided hemiplegia, muscle weakness, and a history of falling, experienced 12 falls between November 2024 and February 2025. The facility's interventions, such as ensuring the call light was within reach and frequent room checks, were insufficient to prevent further falls. The resident reported that she often had to wait too long for staff assistance, leading her to attempt transfers on her own, which contributed to her falls. The facility's policy required the interdisciplinary team to assess and evaluate fall risks and implement a plan of care for high-risk residents. However, the facility did not effectively implement or update fall interventions following each incident, nor did it adequately identify the root causes of the falls. This lack of effective intervention and supervision resulted in repeated falls and injuries for both residents.
Failure to Prevent Repeated Falls and Injury Due to Inadequate Supervision and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with a history of falls and dementia from repeated falls, resulting in injury. The resident experienced multiple falls over several months, including incidents on 10/26/2024, 12/1/2024, 12/24/2024, 12/27/2024, and 2/28/2025. Despite these repeated events, fall risk assessments were either incomplete or did not accurately reflect the resident's fall history, and the total risk scores were not documented. The care plans were updated only after several falls had already occurred, and interventions to address the resident's high risk for falls were not clearly documented or implemented in a timely manner. On 2/28/2025, the resident suffered another unwitnessed fall, resulting in a laceration to the left eyebrow that required first aid and transfer to a general acute care hospital for further evaluation and treatment. Documentation indicated that the resident was found in a crouching position in bed, confused and disoriented, with a bleeding cut above the left eye. The injury was managed by nursing staff, and emergency services were called. The resident's family had previously suggested increased supervision, such as moving the resident closer to the nurse's station, but this was not implemented prior to the incident. Interviews with facility staff revealed gaps in communication and understanding of the significance of the injury. The administrator did not report the unwitnessed fall to the state health department, stating he did not consider the laceration and bleeding to be significant, and was unaware of the medical implications due to lack of clinical training. Facility policy required safety risk evaluations and reporting of unwitnessed falls with significant injury, but these procedures were not consistently followed, contributing to the deficiency.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and timely interventions to prevent multiple falls for a resident known to be at high risk for falls. The resident, who had severe cognitive impairments and a history of falls, experienced seven falls over a period of less than two months. These falls were often related to the resident's attempts to self-transfer in and out of bed, particularly around meal times, and were compounded by the resident's incontinence and memory deficits. Despite being aware of the resident's routine and risk factors, the facility did not consistently implement care-planned fall interventions, such as ensuring the bed was in a low position and using a pool noodle for safety. The resident's care plan included various interventions to mitigate fall risks, such as reminders to use a call light, ensuring appropriate footwear, and monitoring for changes in gait and cognition. However, these interventions were not effectively implemented or updated in response to the resident's repeated falls. For instance, the resident was found without the recommended gripper socks or with the pool noodle improperly placed, and staff failed to consistently assist with transfers before and after meals. The facility's failure to adapt and enforce these interventions contributed to the resident's continued falls, one of which resulted in a hip fracture. The facility's documentation and incident reports revealed inconsistencies in the timing and assessment of falls, as well as a lack of timely review by the interdisciplinary team. The resident's falls were often unwitnessed, and the root causes were not adequately addressed. Despite the resident's significant memory deficit and impulsivity, the facility continued to rely on verbal reminders and education, which were ineffective given the resident's cognitive impairments. This lack of proactive and consistent intervention ultimately led to the resident's decline and the decision to place the resident on hospice services.
Failure to Implement Timely Fall Interventions for Cognitively Impaired Resident
Penalty
Summary
The facility failed to implement timely and appropriate fall interventions for a resident with severe cognitive impairment and a history of falls. The resident, who had diagnoses including dementia, muscle weakness, and unsteadiness, experienced multiple unwitnessed falls over several months. After an initial fall, the only intervention added was to have the resident seen by a primary care physician, which did not occur until after a subsequent fall. No additional fall prevention measures were implemented between the first and second falls, despite the resident's inability to comprehend or use a call light and a care plan indicating the need for two-person assistance and mechanical lift for transfers. Further review showed that after each fall, interventions were added to the care plan, such as scheduled toileting and reminders not to self-transfer, but these were not implemented in a timely manner to prevent repeat incidents. The DON confirmed that no other interventions were put in place after the initial fall and acknowledged that additional measures should have been taken to reduce the risk of further falls. The lack of prompt and adequate intervention contributed to the resident experiencing repeated falls.
Failure to Provide Adequate Supervision for Fall Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as a fall risk, resulting in multiple falls. The resident, an elderly male with severe unspecified dementia, anxiety, and altered mental status, was admitted with a care plan indicating a risk for falls due to weakness and a new environment. On two separate occasions, the resident was left unsupervised or insufficiently supervised due to staffing shortages. On one occasion, the resident attempted to go to the bathroom alone, fell, and hit his head, requiring hospital evaluation. Staff interviews confirmed that the resident should not have been left alone and that the unit was short-staffed at the time of the incident. On another occasion, the resident, who was supposed to be kept in the common area for supervision, was able to stand up and fall before staff could intervene, again resulting in a head injury and hospital evaluation. Documentation and staff statements consistently indicated that the resident was not provided the necessary supervision as outlined in his care plan, and that staffing levels were below normal on both days when the falls occurred. The facility's records confirmed the occurrence of both falls within a short period.
Failure to Prevent Repeated Falls and Injuries in High-Risk Resident
Penalty
Summary
The facility failed to ensure a resident at risk for falls was adequately supervised and monitored, resulting in repeated falls and injuries. Despite being identified as a fall risk due to a history of falls, dementia, muscle wasting, and unsteady gait, the resident experienced three separate falls over a six-month period. The care plan, titled 'Falling Star Program,' included interventions such as keeping the bed in the lowest position, locking wheelchair wheels, maintaining a clutter-free environment, and using non-skid footwear. However, these interventions were not consistently implemented or revised after each fall, and the effectiveness of the care plan was not evaluated following subsequent incidents. After each fall, documentation showed that the interdisciplinary team (IDT) and staff did not adequately address or update interventions to prevent future falls. For example, after the resident was found on the floor with injuries, the care plan was not revised to include more intensive supervision or additional safety measures. The facility also failed to ensure the resident's environment was free from hazards, as evidenced by an incident where the resident slipped on a puddle of urine by the bedside, leading to a severe hip fracture that required surgical intervention. Observations further revealed that the resident's call light was not within reach, and the resident was seen attempting to get out of bed unsupervised, stepping on a wet floor mat. Interviews with staff confirmed lapses in supervision and environmental safety. The DON acknowledged that the resident should have been placed on one-to-one care with a sitter, as outlined in the care plan, but this was not done. Additionally, staff failed to follow the facility's own policies and procedures regarding fall risk management, which required re-evaluation and modification of interventions after each fall. These failures directly contributed to the resident's repeated falls and resulting injuries.
Inadequate Fall Prevention Measures in LTC Facility
Penalty
Summary
The facility failed to implement and revise fall interventions for several residents, leading to multiple incidents of falls. Resident 5, who had a history of various medical conditions including dementia and Parkinson's disease, experienced several falls due to inadequate supervision and failure to ensure the functionality of fall alarms. Despite being identified as a high fall risk, the resident was often left unsupervised, and the fall alarm was not consistently attached or functioning. The care plan interventions were not effectively monitored or updated to prevent further falls. Resident 19, diagnosed with Alzheimer's disease and other conditions, also experienced multiple falls. The resident's care plan included the use of a motion sensor alarm and video monitoring, but these measures were not consistently implemented. The resident was left unsupervised, and the video camera was not properly positioned to monitor the resident. The facility failed to document staff re-education and did not develop new interventions to address the resident's fall risk effectively. Resident 15, with severe cognitive impairment and a history of falls, was not adequately supervised despite being at high risk for falls. The resident's care plan required hourly checks and supervision when in a wheelchair, but these interventions were not consistently followed. The resident was often left alone, and the bed was not maintained in a safe position, contributing to the risk of falls. The facility's failure to implement and monitor fall prevention strategies resulted in repeated incidents of falls for these residents.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement adequate interventions to prevent falls for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including dementia, depression, hypertension, and low back pain, experienced multiple falls over several months. Despite the implementation of various interventions such as physical and occupational therapy evaluations, frequent checks, and the use of alarms, the resident continued to fall. The care plan included the use of fall mats on both sides of the bed, but during an observation, it was noted that the mats were not in place, indicating a lapse in following the prescribed interventions. The facility's Fall Prevention Program policy aims to ensure resident safety by assessing fall risks and implementing appropriate interventions. However, the failure to consistently apply these interventions, as evidenced by the absence of fall mats during an observation, suggests a deficiency in the facility's adherence to its own policies. This oversight was confirmed by a Licensed Practical Nurse/Care Plan Coordinator, who acknowledged that the resident should have had fall mats on both sides of the bed, highlighting a gap in the supervision and implementation of fall prevention measures.
Failure to Provide Adequate Supervision Resulting in Resident Falls
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including moderate cognitive impairment, osteoporosis, and dementia, was not provided with adequate supervision to prevent falls. The resident had a documented history of falls, impaired mobility, and required assistance with activities of daily living (ADLs) and transfers. Despite these needs, the care plan interventions prior to the falls primarily included having the call light within reach, staff assistance for transfers and toileting, and the use of non-slip socks or shoes during mobility. However, the resident experienced two falls within a short period, one in the bathroom while attempting to transfer from the wheelchair without assistance and another after falling asleep in the wheelchair and sliding to the floor. Documentation and staff interviews revealed that the resident had reported using the call light for assistance but experienced significant delays in staff response, sometimes waiting an hour or more. The resident stated that due to these delays, he attempted to perform tasks independently, leading to falls. Staff interviews indicated inconsistent awareness of the resident's fall risk status and interventions, with one CNA unaware that the resident was a fall risk prior to the incidents and noting the absence of a yellow armband, which was supposed to indicate fall risk. The care plan and interventions were not consistently communicated or implemented among staff, and there was a lack of timely and effective supervision tailored to the resident's needs. The facility's policy required providing an environment free from accident hazards and adequate supervision to prevent avoidable accidents. Despite this, the resident's increased weakness, cognitive impairment, and history of falls were not sufficiently addressed through effective supervision or timely staff response. The lack of prompt assistance and inconsistent implementation of fall prevention interventions contributed to the resident's repeated falls and subsequent injuries, including compression fractures and increased back pain.
Failure to Provide Adequate Supervision for High Fall Risk Resident During Toileting
Penalty
Summary
A deficiency occurred when a resident, identified as high risk for falls due to multiple medical conditions including schizoaffective disorder, metabolic encephalopathy, unsteady gait, repeated falls, and vertigo, was not provided with adequate supervision during toileting. The resident had a documented history of falls and was enrolled in the facility's Falling Star Program, which visually identified her as a fall risk. Despite care plan interventions specifying that staff should fully assist the resident during restroom use and ensure safety during transfers, these interventions were not followed on the day of the incident. On the day of the event, the resident called out for help to use the bathroom, but staff did not respond promptly. The resident independently used her wheelchair to access the bathroom. A staff member responded to the resident's wheelchair alarm, found her in the bathroom, and offered assistance, which the resident declined. The staff member then left the resident alone in the bathroom, did not notify other staff, and did not activate the emergency call light. Shortly after, the resident attempted to transfer herself from the toilet to her wheelchair, which was not locked, and fell, resulting in a severe right ankle fracture. Interviews and record reviews confirmed that the resident required supervision or touching assistance with toileting, as indicated in her care plan and MDS assessment. Staff acknowledged awareness of the resident's fall risk status and the need for supervision, but failed to implement the required interventions. The resident suffered a displaced bimalleolar ankle fracture, required emergency transport, pain management, and subsequent surgery to repair the injury.
Failure to Implement and Follow Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when staff failed to implement and follow fall prevention interventions for a resident with a significant history of falls and multiple risk factors, including cerebral infarction, traumatic subdural hemorrhage, repeated falls, parkinsonism, vertigo, muscle weakness, and lack of coordination. The resident required assistance with transfers, toileting, and personal care, and had documented care plan interventions specifying that staff should not leave the resident alone in the restroom and should maintain a toileting schedule. Despite these interventions, the resident experienced multiple falls, including two with major injuries, during the review period. On two separate occasions, staff left the resident unattended in the bathroom, directly contrary to the care plan. In one instance, a nursing assistant left the resident standing in the bathroom to assist another staff member, resulting in the resident falling and sustaining a head laceration and a lumbar compression fracture. In another incident, a nursing assistant left the resident on the toilet to retrieve a bandage, and the resident fell, suffering a thoracic compression fracture and a rib fracture. Interviews confirmed that staff were aware of the care plan interventions but did not consistently follow them, and some staff were unclear about the specific interventions or how to access them in the electronic medical record or on report sheets. Additionally, the facility failed to implement a specific toileting schedule for the resident, despite this being an intervention listed in the care plan and facility policy. Staff interviews revealed that toileting was generally performed at routine times or as needed, rather than according to an individualized schedule. Observations also showed that the resident's call light was not always within reach, another care plan intervention that was not consistently followed. These failures to implement and adhere to established interventions contributed to the resident's repeated falls and injuries.
Failure to Implement Fall Interventions and Document Falls
Penalty
Summary
The facility failed to implement fall interventions, document falls in medical records, perform safe transfers, and thoroughly investigate falls for three residents. Resident 1, who has moderate cognitive impairment and is dependent on staff for transfers, experienced a fall while being assisted into a recliner with a sit-to-stand lift. The fall was not documented in the resident's medical record, and the Assistant Director of Nursing confirmed that falls should be documented in a nursing note. Resident 2, with severe cognitive impairment and requiring substantial assistance for transfers, experienced multiple falls. One fall occurred when a CNA assisted the resident into a chair without using a gait belt or having a second staff member present, despite the resident's care plan requiring two staff for transfers. Another fall was unwitnessed, and the investigation lacked staff statements or interviews to determine when the resident was last observed or toileted. Resident 6, who has severe cognitive impairment and is at risk for falls, experienced several unwitnessed falls. The care plan included an intervention for a nonskid mat, but it was not present in the resident's wheelchair. The fall investigations did not include staff interviews or documentation of when the resident was last observed or provided toileting assistance. The Assistant Director of Nursing confirmed the lack of documentation and awareness of the nonskid mat intervention.
Inadequate Supervision Leads to Recurrent Falls for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a high fall-risk resident, resulting in two unwitnessed falls. Resident 1, who has a history of falls, dementia, and impaired cognition, experienced falls on 2/5/2025 and 3/19/2025 while attempting to ambulate to the bathroom without assistance. Despite being identified as a high fall risk, the resident was not adequately supervised, leading to these incidents. Resident 1's care plan included interventions such as using call lights for assistance and providing help with activities of daily living. However, the resident's cognitive impairments and tendency to overestimate their abilities were not sufficiently addressed, as evidenced by the resident's repeated attempts to ambulate independently. Interviews with facility staff revealed that the resident often did not ask for assistance and had a history of frequent falls, indicating a need for more direct supervision. Observations and interviews highlighted the resident's confusion and reluctance to seek help, as well as the facility's lack of effective fall prevention measures, such as bed alarms or a consistent one-to-one observation. The facility's policy on fall risk management was not effectively implemented, as the resident continued to experience falls despite being identified as high risk. The staff's acknowledgment of the need for a sitter or other interventions came only after the falls occurred, indicating a gap in proactive fall prevention strategies.
Failure to Implement Effective Fall Interventions for High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement effective fall interventions tailored to the root cause for a resident with multiple falls. The resident, who had diagnoses including Parkinson's disease, functional quadriplegia, difficulty in walking, and orthostatic hypotension, experienced six falls over a six-month period. Despite being identified as a high fall risk, the interventions added after each fall were largely repetitive and did not address the underlying causes of the falls, such as the resident's attempts to self-transfer or refusal to use the call light for assistance. Documentation revealed that after each fall, interventions such as encouraging the use of the call light, keeping the environment safe, and providing education were repeated, even though the resident continued to fall in similar circumstances. There was no evidence of new or different interventions being implemented after repeated falls of the same nature. Staff interviews confirmed that interventions were often repeated, and there was a lack of clarity among staff regarding how fall interventions were chosen or evaluated for effectiveness. Some staff were unable to recall what interventions were put in place after specific falls, and there was no documentation of reassessment or modification of interventions when falls recurred. The facility's policy required that interventions be individualized and adjusted if falls recurred, and that staff monitor and document the effectiveness of interventions. However, the report shows that the same interventions were used multiple times without documented assessment of their effectiveness or consideration of alternative strategies. The resident's continued decline and repeated falls, despite these interventions, indicate that the facility did not adequately address the root causes of the falls as required by their own policy.
Failure to Complete Timely Fall Assessment and Interventions After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple risk factors for falls, including alcohol-induced dementia, reduced mobility, history of falling, unsteadiness, and muscle weakness, experienced a fall. The resident required supervision and assistance with several activities of daily living and had a documented fall with no injuries prior to the incident. The care plan included interventions such as keeping the call light within reach, educating on walker use, and providing environmental cues. However, after the resident's fall, a fall assessment was not completed as required by facility policy. The LVN responsible for the resident did not complete the fall assessment or implement new interventions following the fall. Although the resident was found on the floor with a twisted knee and reported pain, and appropriate notifications and neuro checks were initiated, the required fall assessment was not performed. The ADON was notified of the fall and requested the LVN to return to complete the assessment, but the assessment was delayed and not completed in a timely manner. The DON and Administrator both confirmed that assessments should be completed after every fall to ensure appropriate care and interventions are provided. Facility policy mandates that a fall risk assessment be completed after each fall, with interventions updated as indicated. The failure to complete the assessment meant that the resident did not receive a timely evaluation of her condition or updated interventions to prevent further incidents. This lapse in protocol could result in residents not having the necessary resources or supervision to ensure their safety and appropriate care.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions were in place to prevent falls for a resident identified as being at risk for falls. The resident, who was cognitively intact and required substantial to maximal assistance with mobility and toileting, experienced five falls over a short period. Despite being assessed as low risk for falls initially, the resident's fall risk was later updated to high risk after multiple incidents. The care plan was updated with new interventions after each fall, except for the last incident, where no new intervention was added. Observations revealed that the resident's personal items were not within reach, which could have contributed to the falls. The Director of Nursing acknowledged the oversight and indicated that staff were re-educated on following fall interventions. The facility's policy on managing falls emphasized the need for a resident-centered fall prevention plan and the importance of monitoring and documenting the resident's response to interventions. However, the repeated falls and lack of timely updates to the care plan suggest a failure in implementing and adhering to these policies effectively.
Inaccurate MDS Coding for Resident Fall
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident in the area of falls. The resident, who was admitted to the facility, experienced a fall from her bed, as documented in a nursing progress note. Despite this incident, the resident's quarterly MDS assessment incorrectly indicated that she had no falls since her prior assessment. The MDS Coordinator, responsible for coding the assessment, acknowledged the oversight, stating that she typically reviewed progress notes for such information. The fall occurred after the date of the resident's prior MDS assessment, and thus should have been included in the subsequent assessment. Interviews with the Director of Nursing and the Administrator confirmed that MDS assessments should accurately reflect the resident's status.
File Reference
Referenced Text:
Critical Element Decisions:
1) Based on observation, interviews, and record review, did the facility ensure the resident’s environment is free from accident hazards and each resident receives adequate supervision to prevent accidents?
If No, cite F689
File Reference
Referenced Text:
Accidents Critical Element Pathway – Page 1
Observations for all areas:
Is the resident being supervised and interventions implemented as care planned?
File Reference
Referenced Text:
Fall Observations (Page 2):
Do staff respond to the resident’s requests for assistance (e.g., toileting)?
What interventions are implemented to prevent falls? For example, responding to the resident’s requests timely; low bed, fall mat, proper footwear …
File Reference
Referenced Text:
Record Review – Page 6:
Has the care plan been reviewed, revised to reflect any changes because of an accident(s) or change in risk(s), and evaluated for effectiveness?
File Reference
Referenced Text:
Record Review – Page 6:
Based on a review of the most recent MDS Assessment (J1900), if the resident had a fall(s), is the MDS coded accurately for falls in each category (no injury, injury except major, major injury)?
File Reference
Referenced Text:
Environmental & Fall Observations – Page 2:
What interventions are implemented to prevent falls? For example … resident’s room is free from accident hazards (e.g., adequate lighting, assuring no trip hazards, providing assistive devices).