In last week’s post, CMSCG explored elopement and what can go wrong related to a facility’s elopement prevention program, even if it is comprehensive. Unfortunately, we heard about two elopements since publishing that post only a few days ago – even more of a reminder to review your systems for accident prevention! This week we are going to explore Falls Prevention, which is an area that has frequent negative outcomes for residents, and discuss how a facility can potentially strengthen its fall prevention program.
Best Practices for Fall Prevention in the Nursing Home
First of all, we need to understand that not every fall is preventable. This is especially important to understand when you develop and implement an individualized falls risk plan, but the resident is determined by the IDT as non-complaint with the prevention plan that you have diligently put in place. I hope that you have evidence of ongoing education of the resident related to the resident’s part in fall prevention when the resident is capable of understanding the potential consequences of non-compliance. The falls risk plan should include evidence of factoring in the resident’s preferences related to getting up and going to be times, naps, toileting/retraining schedules, etc. Don’t be too hasty in labeling a confused, demented resident as non-compliant when they have no capacity to understand your directions to use the call bell to request assistance. These directions are so inappropriate in preventing a fall for a resident with a low BIMS score. When a resident can’t help him or herself, staff need to step in to assist with accident prevention and appropriate supervision.
Residents should be assessed for fall risk on a routine schedule as well as whenever there is an identified change in the resident’s fall risk factors or an actual fall. The problem with this is that the staff is not always good at identifying the change in resident needs or reporting it.
The Nurse Manager needs to know when the resident now needs increased staff assist to transfer; timely reporting needs to occur – not days later when the resident falls and fractures a hip or sustain a subdural hematoma because of a head strike. Such changes can’t be written off by the Nursing Assistant that the resident is tired today because they did not sleep well last night or are just not cooperating with care so why report anything? Worse yet, when questioned, the staff member reports, “I forgot.”
Falls from Lifts
Falls from lifts frighten me for so many reasons – mainly because there is such a chance of harm to the resident. Think of the resident who slid out of a lift sling that was too large and lacerated their head or staff not getting the required second staff member to assist in a mechanical lift transfer and the resident “drops” to the floor when the lift is in the raised position, sustaining significant injuries that required transfer to a trauma center. A facility was cited with a harm level deficiency when the bolt holding the sling bar sheared off and the resident fell to the ground and a serious injury sustained. Is there a Preventative Maintenance Program in place for your lifts?
Monitoring for Fall Prevention
In any falls prevention discussion, there is always a place for a lively discussion on the use and value of 1:1 monitoring by a staff member or use of an electronic monitoring system, which has become more popular of late. Staff assigned to monitoring need to be educated on the meaning of 1:1 monitoring, understand their responsibility related to providing this service and should be monitored for compliance with completing their responsibilities. Issues that come up with 1:1 are frequently related to staff not paying attention to the resident (they are usually on their phone or talking to other staff), being farther away from the resident than they should be, or the relief staff not reporting to monitor the resident and the assigned staff member goes on break anyway.
All providers know the basics of what should be included in a facility’s Fall Prevention Program as do most caregivers. The issue with falls is usually that we did not individualize the plan of care, update it when needed or ensure that it was adhered to. Falls Prevention, in general, should be a priority item for all QAPI Programs to monitor. When CMSCG conducts a quality review/mock survey for clients, falls are always scrutinized. Why is this done, you might ask. Pretend you are a surveyor and are reviewing the CMS-802 form and the number of residents coded for a fall or fall with major injury appears unacceptably high. You should be keeping in the back of your mind when looking at some of these falls with or without injury — was the individual prevention plan followed? Was it actually individualized for that resident’s needs?
Assessment of the fall should include:
- determining if the plan of care was followed
- if an Occurrence Report was completed
- if an appropriate report was made to the Department of Health/ Department of Public Health when reporting criteria was met
- If a comprehensive investigation completed.
Geez, if you get lucky in your review (as a surveyor) you can probably cite the facility at F-689 Accidents/Supervision, F-610 Investigations and, if you really lucky, you can go for the trifecta by citing F-609 Reporting as well. I am not really joking here as that is how a fall investigation can go. I am sure that some of you reading this may have seen this scenario play out in your facility or know of a colleague who faced such circumstances. The importance of having a strong, comprehensive Falls Prevention Program can never be downplayed.
Ftag Series Wrap-Up
As we wrap up this F689 series, one theme has been impossible to ignore: high‑risk events are rarely unpredictable. Whether it’s a fall, an elopement, or another serious incident, surveyors consistently find the same patterns — incomplete assessments, weak systems, and staff who were never fully supported with the training, tools, or clarity they needed. When those gaps collide, facilities don’t just face an accident; they face the possibility of multiple citations (including F689, F610, F609, F684 and more).
A strong, comprehensive Falls Prevention Program — and equally strong systems for elopement prevention, behavioral health risk management, and accident oversight — is not optional. It’s foundational. The facilities that stay out of Immediate Jeopardy are the ones that treat accident prevention as a living system, not a binder on a shelf. As you reflect on this series, consider where your own systems may be drifting and where your team may need reinforcement. Prevention is always possible when the right structures are in place.
If this series has raised questions about the strength of your fall, elopement, or accident‑prevention systems, CMS Compliance Group can help. Our consultants work with facilities to assess vulnerabilities, strengthen protocols, and prepare staff to prevent high‑risk events — and the citations that follow. Contact us to learn how we can support your team.
