Failure to implement care-planned fall prevention interventions for a resident with repeated falls. The resident had poor balance, an unsteady gait, and psychotropic med use, and the care plan included bedside Dycem, non-slip footwear, a walker within reach, and staff cueing for transfers and toileting. Surveyors observed the resident barefoot at the bedside with no Dycem in place, and staff interviews confirmed the intervention was not implemented as care planned.
Failure to identify fall causes and update care plan after fracture: A resident with depression, dementia, HTN, and prior hip/pelvic injuries fell, was found on the floor beside the bed barefoot, and was sent to the ER where x-rays showed a nondisplaced pelvic fracture. The care plan listed prior falls and interventions, but no new fall interventions were added after the event, and the risk forms used vague “other” entries without explaining the causative factors. The DON confirmed the fall and fracture were not added to the care plan.
Failure to Investigate Falls and Update Care Plans: The facility did not thoroughly investigate unwitnessed falls or identify causative factors for several residents with significant medical and functional impairments, including stroke, dementia, hemiplegia, COPD, CHF, CKD, and reduced mobility. For multiple residents assessed as high fall risk, fall reports lacked causative factors and interventions, care plans were not updated after the falls, and the DON/RDON confirmed that no facility investigation was completed.
Failure to implement fall prevention interventions for a resident at high risk for falls. The resident had dementia, Parkinson's disease, diabetes, and severe cognitive impairment, with a care plan calling for a pull alarm on the recliner, a Dicem pad on the wheelchair seat, scheduled toileting, and placement in the recliner for supervision. Surveyors observed the resident in a wheelchair and recliner without the required alarm in place, and the wheelchair lacked the non-slip pad. The resident was also found soiled with urine and feces, and the DON confirmed the resident had multiple recent falls.
Failure to Identify Causes and Individualize Fall Interventions: A resident with severe cognitive impairment, incontinence, and multiple psychoactive meds had repeated falls in the room and bathroom area. The facility often documented no causal factors or used limited interventions such as a reminder sign, med review, video monitoring, and alarms, while not addressing issues noted in the events such as toileting needs, feces in the bathroom, poor lighting, and refusal to wear gripper socks or shoes.
Failure to Implement Elopement Protections: The facility did not consistently implement elopement safeguards for multiple residents with cognitive impairment and wandering or exit-seeking behaviors. One resident with Alzheimer’s disease eloped and was returned by police, while overnight 15-minute checks for several residents were not documented as completed. Another resident with stroke-related cognitive deficits was identified as at risk after trying to leave, but the record showed no elopement interventions in place before the attempt, no wander guard on the resident or wheelchair, and no protected list with photos and descriptions.
A resident with hypotension, repeated falls, and severe cognitive impairment had multiple falls while getting out of bed or self-transferring, including events with skin tears. Fall documentation showed varying initial responses such as slip-resistant socks, gripper socks, shoes, and reminders to call for help, but the DON confirmed that new interventions should have been added after each fall and were not.
Inconsistent process for residents who did not return from leave. Two cognitively intact residents signed out of the facility without clear return times, and staff responses varied when they failed to return as expected. For one resident, the ADM and SSD made repeated contact attempts and searched areas the resident frequented, but APS notification was delayed. For the other resident, staff attempted calls to the resident and ex-wife, but there was no evidence that APS, police, or the physician/NP were notified when contact could not be made.
A facility failed to identify the causes of repeated falls and to base interventions on those causes for two high-fall-risk residents. One resident had dementia, hemiplegia, aphasia, incontinence, wandering, and multiple falls, but the documented interventions included 15-minute checks, reminders not to get up alone, and a bed-positioning cue that did not match the fall causes. Another resident had severe cognitive impairment, Alzheimer’s disease, and hospice services, with falls related to confusion, weakness, pain, toileting, and wandering, yet the interventions were 1:1 supervision and close observation, which the DON said were not measurable and did not address the identified causes.
Failure to Prevent Hot Liquid Burns: Two residents were involved in hot coffee incidents after the facility left coffee accessible at nurse stations without a consistent monitoring system or resident hot-liquid safety assessments. One resident with cognitive impairment, Parkinson’s disease, dysphagia, and weakness spilled coffee on self and sustained burns with blisters to the chest, abdomen, and thigh. Another resident with stroke-related deficits, dysphagia, and dependence for most ADLs was later observed with an uncovered cup of coffee at the nurse’s station and spilled coffee on clothing. Staff and the Administrator confirmed there was no process in place before the incidents to prevent residents from getting hot coffee themselves.
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