F0658

D

Failure to Complete RN Post-Fall Assessments and Keep Resident in Place After Falls

Old Saybrook, Connecticut Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality for a resident with a history of falls and identified as a high fall risk. The resident had multiple psychiatric diagnoses, including catatonic disorder, major depressive disorder, anxiety disorder, delusional disorder, and unspecified psychosis, and required one-person assistance for transfers, ambulation, and positioning. The care plan identified numerous fall-prevention interventions, including environmental modifications, toileting schedules, therapy involvement, and close observation. Despite these identified needs and risks, the facility did not consistently complete required RN post-fall assessments or adhere to its own policy that an RN assess the resident immediately after each fall and before the resident was moved.

On one fall dated 11/21/25, documentation showed the resident got out of bed without assistance, fell, and struck the face and head, sustaining two lacerations above the left eyebrow. The charge nurse, an LPN, completed the SBAR and arranged transfer to the ED, but the nurse’s notes did not document that the nursing supervisor (an RN) assessed the resident following the fall, and the SBAR lacked range-of-motion assessment. On 12/3/25, the resident was found lying on the floor on the left side with minimal swelling to the left temporal region; the nursing supervisor, APRN, and family were notified and neuro checks were initiated, but again the nurse’s notes did not document that an RN assessment was completed, and the SBAR completed by the LPN did not include range of motion.

On 11/23/25, the resident was found on the floor after attempting to transfer from a wheelchair. The charge nurse, an LPN, later reported that she panicked, did not immediately call the RN supervisor, and instead enlisted a nurse aide to help move the resident from the floor to the wheelchair before an RN assessment. She then cleansed the laceration to the right side of the resident’s head and only afterward notified the RN supervisor. The RN supervisor’s subsequent note documented that the resident was already in the wheelchair, had a laceration near the right eye, and could move all extremities, and the resident was sent to the ED. On 12/22/25, the resident was observed sliding backward out of the wheelchair to the floor and possibly hitting the back of the head; the RN supervisor was notified and reportedly assessed the resident immediately, but there was no RN assessment note in the record, the SBAR was incomplete, and range of motion was not assessed. The DON stated that a full RN assessment was required after each fall and prior to moving a resident, and was unaware that full RN assessments had not been completed after several of the resident’s falls.