Hyde Park Healthcare Center

During a

initiated on 12/27/2025, the interventions indicated to do neurochecks, notify the physician (MD), pain assessment and send to hospital for further evaluation. On 2/18/2026 (post third fall), the interventions indicated to determine and address causative factors of the fall. On 2/21/2026 (post fourth fall), the interventions indicated to anticipate and meet resident's needs, call light within reach and encourage us when assistance is needed, ensure resident is wearing appropriate footwear, follow facility fall protocol and review information on past falls and attempt to determine causes of falls.

Record possible root causes and alter or remove any potential causes.

Educate the resident/ caregivers/ IDT (Interdisciplinary Team [group of healthcare professionals, including physician, nurses, resident/ resident representative, working together to develop a plan of care for the residents]) as to causes.

During an interview on 2/25/2026 at 11:25 a.m., with the Director of Nursing (DON), the DON stated he was aware of Resident 1's falls on 12/27/2025, 1/23/2026, 2/18/2026 and 2/21/2026.

The DON stated staff should have implemented new interventions to prevent fall, like rounding and assisting the resident as needed.

The DON stated the interventions indicated in the resident's care plan will not prevent a fall and the revised interventions will not prevent another fall.

The facility did not conduct post fall IDT meetings on 12/27/2025, 1/23/2026, 2/18/2026 and 2/21/2026, with the primary physician, or consulted the pharmacy.

Failure to timely conduct IDT meetings with the primary physician and consulting the pharmacist will increase the risk of Resident 1's falling and sustaining an injury.

During a review of the facility's policy and procedure (P&P) titled, Person Centered Care Plan, dated 12/2026, the P&P indicated the IDT, and resident will discuss and prioritize the resident's needs with input from the resident, develop goals and approaches for each problem that are realistic, specific, measurable and re-evaluate and modify care plans as necessary.

During a review of the facility's P&P titled, Fall Prevention Program, dated 12/2016, the P&P indicated the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.

All residents will be assessed following incident of fall.

The P&P indicated all precautions will be implemented to protect the resident according to the fall preventions and reduction program.

The staff, with the input of the physician, will identify appropriate interventions to reduce the risk of falls. In conjunction with the consultant Pharmacist and Nursing staff, the attending physician will identify and adjust medications that maybe be associated with an increased risk of falling.

The P&P indicated the care plan interventions should include the treatment prescribed by the physician and IDT recommendations, if any.

During a review of the P&P titled, Comprehensive Plan of Care, dated 12/2016, the P&P indicated it is the policy of this facility to provide each resident with a comprehensive plan of care developed that includes goals, measurable objectives and timetables to meet their medical, nursing, mental, psychosocial needs identified during comprehensive assessment.

The comprehensive plan of care should include interventions to attempt to manage risk factors; be developed by an IDT that includes the attending physician, a registered nurse, and other appropriate staff as determined by the resident's needs, be periodically reviewed and revised by the interdisciplinary team, as changes in the resident's care and treatment occur.