F0689

D

Failure to Follow Two-Person Assist Care Plan and Timely Post-Fall Assessment

Chandler, Arizona Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and assistance to prevent a fall and to follow professional standards for post-fall assessment and notification for one resident. The resident was admitted with multiple significant diagnoses, including a periprosthetic fracture around an internal prosthetic right knee joint, hypertension, type 2 diabetes mellitus, chronic kidney disease, acute kidney failure, nonrheumatic mitral valve insufficiency, muscle weakness, and difficulty walking. An annual MDS showed a BIMS score of 7, indicating severe cognitive impairment, and documented that the resident was dependent on staff for toileting hygiene and transfers, requiring the effort of two or more helpers. The care plan identified the resident as at risk for falls due to recent illness, deconditioning, and a new environment, and specified that the resident was a two-person assist for transfers.

On the date of the incident, a 5-day report documented that in the early morning hours the resident "rolled" out of bed and began falling while a CNA was changing the resident’s sheets. The CNA reported that the resident was unable to balance her legs, dropped both legs to the floor, and that he held the resident by the shoulders and let her sit on the floor, then called a nurse, who performed a physical "checkup" and assisted the CNA to put the resident back into bed. Later that morning, another CNA observed the resident crying; the resident stated she had been dropped while a staff member was working with her, that the staff member tried to pick her up but could not, and that he left to find someone else to assist before returning with another staff member to get her back into bed. 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 that when she fell she heard a crack that sounded like a stick breaking. The resident was also observed to be wet, and the CNA expressed fear of causing further pain because the resident was crying and begged not to be moved.

Progress notes and radiology documentation showed delays and gaps in post-fall assessment and notification. A health status note entered that evening documented that the resident complained of left knee pain from a recent fall and was awaiting an x-ray, with swelling noted in the left knee. A fall review note created after midnight the following day indicated that the family, physician, and DON were notified, but there was no evidence in the progress notes of notifications at the time of the incident. A radiology report dated the following day documented a fracture of the distal femoral shaft with slight malalignment. A subsequent health status note recorded that an x-ray performed that morning revealed an acute femoral fracture and that an order was given to send the resident to the emergency room, with transport arriving later that morning. Interviews with nursing staff, including LPNs, CNAs, and the ADON, consistently described facility expectations that care plans be followed for transfers and brief changes, that CNAs not move residents post-fall before a nurse assessment, that pain, swelling, and suspected injury be promptly reported to a physician, and that STAT x-rays or immediate hospital transfer be arranged when serious injury is suspected. The ADON specifically stated that the dates and timing of the x-ray and notifications for this resident did not meet her expectations and that the care plan was not followed, including the requirement for a two-person assist.