MAYVILLE, WI - Federal inspectors cited Crossroads Care Center of Mayville for failing to properly investigate multiple falls by a traumatic brain injury patient and administering incorrect medication dosages during a five-day stay in late June 2024.
Four Falls Without Proper Investigation
A resident with traumatic brain injury and subarachnoid hemorrhage experienced four separate falls between June 29 and July 3, 2024, according to inspection records. The facility failed to conduct comprehensive root cause analyses for any of the incidents, missing critical opportunities to prevent subsequent falls.
The first fall occurred on June 29 at 4:15 PM in a hallway. Documentation noted "improper footwear and ambulating without assistance," but inspectors found no thorough investigation into what the resident was doing at the time or when staff last provided assistance.
Two days later, the resident fell again in their room at 3:10 PM during an unwitnessed incident. Activity staff had taken the resident to use the bathroom but left them alone to seek additional help - despite care plan instructions added after the second fall stating "do not leave alone in room."
The third fall happened from bed at noon on July 3, with staff noting the resident was "looking for their brother" shortly after being put to bed. Later that same day at 6:40 AM, a fourth fall occurred while a staff member was present, as the resident's legs became weak while walking to the bathroom.
Medication Transcription Error
Simultaneously, the facility incorrectly transcribed medication orders from the hospital discharge summary. The resident was prescribed propranolol 10mg twice daily for tremors but received only a single daily dose throughout the stay.
Hospital records clearly documented propranolol 10mg "at breakfast and lunch" for tremors treatment. However, facility physician orders listed the medication as "10mg daily for hypertension" - both an incorrect frequency and wrong medical indication.
The error was discovered after the resident's family requested hospital transfer on July 3, following the fourth fall. A medication occurrence report dated that same day acknowledged the mistake but came too late to correct the resident's care.
Safety Protocol Breakdowns
Fall prevention requires systematic analysis of contributing factors including environmental hazards, medication effects, mobility limitations, and timing of incidents. Nursing homes must implement targeted interventions based on identified risks rather than generic precautions.
The resident's care plan initially included basic interventions like ensuring proper footwear and keeping call lights within reach. After the second fall, staff added wheelchair positioning near the nursing station and later specified not leaving the resident alone. However, these changes failed to address underlying factors contributing to the fall pattern.
Effective fall prevention protocols typically examine medication timing, bathroom schedules, confusion patterns, and mobility assistance needs. Each incident should trigger immediate reassessment of current interventions and implementation of more specific safeguards.
Medication Management Standards
Propranolol is a beta-blocker commonly prescribed for tremor control in neurological conditions. The correct twice-daily dosing maintains steady blood levels necessary for symptom management. Missing doses can lead to breakthrough tremors, potentially increasing fall risk and reducing quality of life.
Standard admission protocols require careful review of hospital discharge orders, with multiple verification steps to prevent transcription errors. The facility's medication occurrence report indicated an assistant director of nursing identified the error during a secondary review, but the correction wasn't implemented in the computer system.
Regulatory Violations
Inspectors cited violations of federal regulations requiring facilities to ensure each resident receives proper pharmaceutical services and maintain environments reasonably free from accident hazards. Both violations received "minimal harm" classifications, indicating no serious injury occurred but potential for harm existed.
The resident's family ultimately requested hospital transfer following the fourth fall, expressing concerns about safety and care quality. The facility's inability to prevent repeated incidents despite multiple opportunities for intervention demonstrated significant gaps in safety protocols.
Crossroads Care Center must submit a plan of correction addressing how it will improve fall investigation procedures and medication transcription verification. The facility has not publicly responded to the violations.
This case highlights the critical importance of thorough incident analysis and accurate medication management in nursing home care, particularly for vulnerable residents with neurological conditions requiring specialized attention to safety and symptom management.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crossroads Care Center of Mayville from 2024-08-15 including all violations, facility responses, and corrective action plans.
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