Divine Providence: Fall Care Plan Failures - MN

The resident, identified as R4 in the April inspection report, had been admitted in February with a history of falls. Her cognitive impairment was so severe she could not understand instructions or express her needs. She required substantial help with daily activities and was incontinent.

On February 17, staff found R4 next to a chair in her room after an unwitnessed fall. She reported thinking she bumped her head when she tried to walk. Her call light was not on. Staff immediately placed alarms on her bed, chair, and wheelchair as a corrective measure.

Five days later, R4 fell again.

Staff discovered her next to a recliner in the facility's living room, leaning on her right side with broken glasses and a cut near her left eye. She had been sitting near a window when she attempted to walk and fell. No staff were in the area because residents were finishing lunch and being transported from the dining room.

This time, staff promised additional safety measures: R4 would remain in the dining room until staff were present in the living room, a staff member would supervise the dining area when she was there, and she would spend as much time as possible in the living room area for supervision.

The second fall fractured R4's pelvis.

Two days later, the facility's interdisciplinary team met to review the fall and confirmed the new intervention of keeping R4 in the living room for supervision "as much as able." But none of these safety measures ever made it into her official care plan.

When federal inspectors arrived in April, they found R4's care plan contained only the original intervention from her first fall: bed and chair sensor alarms. The plan made no mention of the dining room restrictions or increased supervision requirements that staff had identified as necessary after her pelvis-fracturing fall.

Registered nurse RN-A confirmed during the inspection that the interventions from the February 22 fall report had never been added to the care plan. She acknowledged that when falls occur, the charge nurse completes a fall report and is supposed to update the care plan with new interventions. The interdisciplinary team meets weekly to review falls and should also update care plans if interventions change.

"The care plan should be updated any time care needs change for a resident," RN-A told inspectors.

The administrator agreed, saying she would expect R4's care plan to reflect her current care needs, including identified fall interventions. Any time a new intervention or care need was identified, the care plan should be updated.

The facility's own Fall and Post-Fall Assessment policy required that interventions be added to the care plan and communicated to staff following any fall. The policy stated that after a fall, nurses would assess the resident, evaluate the environment for possible causes, notify family and doctors, and add interventions to the care plan.

None of this happened for R4.

R4's medical complexity made the care plan failure particularly concerning. She took scheduled pain medication, antipsychotics, anti-anxiety drugs, antidepressants, a diuretic, and opioids. During the assessment period, she was also on antibiotics. Her diagnoses included dementia with psychotic disturbance, anxiety, cardiac arrhythmia, high blood pressure, depression, osteoporosis, weakness, and malnutrition.

She was receiving both occupational and physical therapy while dealing with delirium, inattention, disorganized thinking, and fluctuating mental status.

The facility had identified R4 as requiring two staff members to assist with transfers and toileting. She had a wander guard on her wheelchair and could not safely transfer without assistance. But the specific environmental and supervision interventions designed after her most serious fall remained absent from her care plan.

Federal inspectors found the violation represented a failure to revise care plans based on comprehensive assessments and changes in resident condition. The finding applied to one resident but highlighted systemic problems with the facility's care planning process.

The inspection occurred more than two months after R4's pelvis-fracturing fall, meaning she had been living with an incomplete care plan that failed to reflect the safety interventions staff had deemed necessary to prevent future injuries.

R4's case illustrates how administrative failures can compound the vulnerability of residents with severe cognitive impairment, leaving them at continued risk even after serious injuries have occurred.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Divine Providence Community Home from 2026-04-15 including all violations, facility responses, and corrective action plans.

Additional Resources

• View all inspection reports for Divine Providence Community Home
• Browse all MN nursing home inspections