F0684

D

Failure to Provide Post‑Fall Assessment and Timely Diagnostics and Failure to Apply Ordered DME for Contracture Prevention

Chandler, Arizona Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary care and services after a fall for one resident and failure to apply ordered durable medical equipment (DME) for another resident. For the first resident, who had multiple diagnoses including a periprosthetic fracture around an internal right knee prosthesis, severe cognitive impairment, muscle weakness, and difficulty walking, the care plan identified the resident as a two‑person assist and at risk for falls. Despite this, a CNA changed the resident’s sheets alone during the early morning hours, during which the resident rolled out of bed and was assisted to the floor by the CNA. The CNA then had the resident sit on the floor and later, along with another staff member, lifted the resident back into bed without a documented nursing assessment prior to the transfer, contrary to staff statements that a nurse should assess a resident before moving them after a fall.

Later that morning, another CNA observed the resident crying and reporting that she had been dropped by staff and that the staff member tried to pick her up but could not, then left to find help. This CNA observed swelling of the resident’s left leg from the knee to the thigh and reported it to the charge nurse, who stated he would take care of it. The same CNA later reported to the ADON that the resident had not yet been checked on, and the resident told the ADON she heard a cracking sound like a stick breaking when she fell. The resident was also observed to be wet, and the CNA expressed fear of causing more pain because the resident was crying and begging not to be moved. Documentation shows that the resident complained of left knee pain from the fall and had visible swelling, but the x‑ray was not completed until the following morning, at which time a distal femoral shaft fracture with slight malalignment was identified and the resident was then sent to the emergency room. The ADON later confirmed that the physician and family were not notified until the day after the incident and that the x‑ray had not been ordered as STAT, which did not align with facility policies requiring prompt notification of changes in condition and labeling emergency diagnostic requests as STAT.

For the second resident, who had diagnoses including a right humeral neck fracture, Parkinson’s disease, dementia with severely impaired cognition, difficulty walking, and need for assistance with personal care, the physician had ordered multiple DME items: a PRAFO boot to the left lower extremity to be worn all day with shift skin checks, an AFO to the left lower extremity when up in a wheelchair, and a left hand roll to be on at all times except during meals, with skin checks. The care plan included interventions to encourage use of the affected limb, maintain range of motion, and monitor for muscle rigidity and decline in range of motion. On multiple observations over several days, the resident was seen in the hallway, dining room, and activities area without the PRAFO boot, AFO, or left hand roll in place, and with a left hand contracture and both feet turned inward while seated in a wheelchair.

Review of the MAR/TAR for January showed check marks indicating that the AFO, PRAFO, and hand roll orders were carried out on certain shifts, but surveyors’ observations did not corroborate that the devices were in use. Review of the MAR/TAR for the prior month showed no documentation of administration of these ordered devices. An LPN stated that the PRAFO boot is used to keep the feet straight and that the hand roll is to stop the hand from contracting, and acknowledged that the devices had not been placed on the resident despite documentation indicating otherwise. The LPN reported that staff had stopped placing the devices because the resident would remove them and because the boots were believed to be causing leg wounds, but also stated there was no documentation that the family had been consulted, that the physician had been notified, or that the resident did not tolerate the devices. A CNA confirmed that the resident had not worn the boots for a while because they were hurting her legs, but that she had not been informed to stop placing the DME. The ADON stated that staff were expected to follow physician orders or notify if there was a concern and acknowledged that failure to follow DME orders could cause further contracture or limited range of motion, but no documentation was provided to show that the ordered DME had been consistently applied or that the orders had been modified.