BROOKFIELD, WI - An inspection at Congregational Home revealed significant deficiencies in fall prevention protocols after a resident with severe dementia experienced 14 documented falls over a seven-month period without proper investigation or consistent implementation of safety measures.
Inadequate Fall Investigation Procedures
The inspection identified systematic failures in the facility's fall investigation process for a resident with severe cognitive impairment who was on hospice care. The resident, who had a Brief Interview Mental Status score of 3 out of 15 indicating severe cognitive impairment, experienced multiple falls from a specialized Broda chair designed for high-risk patients.
Despite facility policies requiring comprehensive post-fall documentation including statements from staff who last saw the resident and witnesses, inspectors found that most fall reports lacked these critical elements. For falls occurring on July 22, July 24, September 11, October 24, November 9, and November 24, 2024, no statements were included regarding who last saw the resident or what the resident was doing prior to the fall.
The facility's own procedures mandate that charge nurses complete detailed forms after any fall, including notes from appropriate staff providing care and witnesses. However, the inspection revealed that these requirements were consistently not met, compromising the ability to identify root causes and prevent future incidents.
Specialized Equipment Safety Protocols Ignored
The resident required use of a Broda chair, a specialized reclining chair designed to prevent falls in high-risk patients. The manufacturer's operating manual specifically states that the chair's seat should be "tilted sufficiently to prevent the resident from sliding or falling forward off the chair."
Despite this clear guidance and multiple falls documented as the resident "sliding out" of the chair, facility staff repeatedly failed to ensure proper positioning. On July 29, 2024, the post-fall report specifically noted that "resident's Broda chair wasn't reclined according to resident's plan of care when resident's fall occurred."
This represented a direct violation of both the manufacturer's safety recommendations and the facility's own care plan requirements. The resident's care plan had been updated after earlier falls to specify that the Broda chair should be "slightly reclined when resident is in Broda chair," yet staff continued to fail in implementing this basic safety measure.
Delayed Implementation of Safety Interventions
The inspection revealed significant delays between identifying necessary safety interventions and their implementation in the resident's care plan. After the resident's fall on July 22, 2024, facility staff recommended ensuring the Broda chair was properly reclined, but this intervention was not added to the fall care plan until July 24 - after another fall had already occurred.
Similar delays occurred with other safety measures. Following a fall on July 24, staff identified that the resident became restless when needing incontinence care changes, but this intervention was not incorporated into the care plan until July 29, five days later.
Medical Context and Risk Factors
Falls in nursing home residents with severe dementia carry significant medical risks. Residents with cognitive impairment have difficulty recognizing safety hazards and may attempt unsafe transfers without assistance. The resident in this case had multiple risk factors including unspecified dementia with psychotic disturbances, seizure disorder, and was assessed as having a high fall risk score.
Proper positioning of specialized seating equipment is critical for preventing falls in residents with cognitive impairment who may attempt to transfer independently. When safety equipment like Broda chairs is not positioned according to manufacturer specifications, the protective benefit is eliminated, potentially increasing fall risk rather than reducing it.
Supervision Requirements Not Met
The facility's own protocols required enhanced supervision during shift changes, when staffing transitions can create gaps in resident monitoring. The resident's care instructions specifically stated "at shift change someone needs to be with resident" and "resident not to be left alone at shift change."
Despite these clear requirements, the August 5, 2024 fall occurred specifically because the resident was left unattended during shift change, according to the facility's own post-fall analysis. This represented a direct failure to follow established safety protocols designed for this high-risk resident.
Management Oversight Deficiencies
The inspection revealed significant delays in management review and approval of fall reports. Post-fall reports that should have been promptly reviewed and signed by nursing management were delayed for weeks or months. For example, the July 24 fall report was not signed by the Nurse Manager until August 6 and not reviewed by the Director of Nursing until August 19.
These delays prevented timely implementation of corrective measures and demonstrated inadequate management oversight of safety incidents involving vulnerable residents.
Additional Issues Identified
The inspection also documented failures in basic care protocols, including inconsistent implementation of the resident's requirement for incontinence checks every two hours. On the day of inspection, staff acknowledged the resident had not been checked and changed on schedule despite this being a documented intervention for fall prevention.
The facility's fall prevention program requires systematic investigation, timely implementation of interventions, and consistent management oversight - all of which were found to be deficient in this case involving a highly vulnerable resident with multiple risk factors.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Congregational Home, Inc from 2025-02-05 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.