The Haven Of Bement.

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

disorder, reduced mobility, mild neurocognitive disorder, hearing loss, difficulty walking, muscle wasting and atrophy, gait and mobility abnormalities, muscle weakness, macular degeneration, urinary incontinence, and a cognitive-communication deficit.Resident R3's MDS dated [DATE REDACTED] documents Resident R3 as moderately cognitively impaired, requiring maximum staff assistance for bed mobility and dependency for oral hygiene, toileting, bathing, dressing, personal hygiene, and transfers.Resident R3's Care Plan intervention dated 6/13/2020 mandates use of a total-body mechanical lift with two staff for all transfers. A fall intervention added 8/23/24 directs lowering Resident R3's wheelchair seat; another intervention added 8/28/24 requires an alarm in his wheelchair. No fall intervention was added following the 9/23/25 fall.Resident R3's Fall Risk assessment dated [DATE REDACTED] classifies Resident R3 as high fall risk.Resident R3's Nurse Progress Notes:7/2/25 at 4:54?AM: Resident R3 was found sitting on the floor beside his bed. He stated he had attempted a self-transfer.7/4/25: The notes lack documentation about a fall at 9:29?PM.8/8/25 at 5:18?AM: Resident R3 was found beside his bed on the floor and said he tried to self-transfer.9/23/25: Notes omit details of a fall at 1:40?AM.Resident R3's Fall Investigations:7/2/25: An unwitnessed fall at 4:30?AM occurred when Resident R3 was trying to get up and was incontinent. The investigation does not include a root?cause analysis.7/4/25: An unwitnessed fall at 9:29?PM found Resident R3 lying next to his bed and incontinent. No root?cause is provided.8/8/25: An unwitnessed fall at 4:15?AM left Resident R3 on the floor beside his bed; he said he attempted to self-transfer. No root cause is documented.9/23/25: An unwitnessed fall at 1:40?AM found Resident R3 on the floor beside his bed and incontinent. The investigation notes that Resident R1 was unable to describe the fall. No root cause is identified.On 10/10/25 at 9:35?AM, V11 CNA transferred Resident R3 from his bed to his wheelchair without additional staff, without a mechanical lift, and without a gait belt.At 9:40?AM, Resident R3 was in his wheelchair in the dining room drinking hot coffee. No staff were present. His wheelchair seat was not lowered, and no personal alarms were installed.At 10:00?AM, V11 CNA admitted she transferred Resident R3 without help, without the lift, and without a gait belt. She said she knew two staff and a mechanical lift were required but sometimes does not follow that. She said staff practices vary-sometimes using the lift, sometimes physically transferring Resident R3.At 10:15?AM, V7, Director of Rehabilitation Services, assessed Resident R3's wheelchair. She observed the seat was in its highest position, though it could be lowered. She said wheelchair adjustments are normally reviewed with therapy. She was unaware that Resident R3's Care Plan includes lowering the seat.At 11:25?AM, V1 Administrator stated that Resident R3's fall interventions did not align with his falls

on 7/2/25, 7/4/25, 8/8/25, and 9/23/25, particularly because no root causes were documented. The Administrator said that when a resident falls, the interdisciplinary team (IDT) should discuss the fall, implement an appropriate intervention plan, and educate staff. She said merely documenting what happened is insufficient to identify a root cause. She commented: Just because (Resident R3) tries to get up on his own does not tell us why he is attempting to get up. The root cause might be incontinence, hunger, pain, etcetera.She concluded that the root causes of Resident R3's falls were never determined.The facility policy titled Falls Guideline, revised August 2024, defines a fall as any failure to maintain appropriate lying, sitting, or standing position that results in unintentional relocation to the ground or another object lower than the starting point. It mandates that all residents at fall risk be reviewed for individualized interventions. Fall management should include review of physical devices, hazard analysis, cause identification, intervention development and implementation, and ongoing evaluation. Staff must evaluate and document all falls-including when and where they occurred and observational details. Documentation should contain sufficient information to help determine the cause of the fall.

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