F0689

D

Failure to Complete and Document Post-Fall Vital Signs and Neuro Checks After Two Falls

Clearwater, Florida Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete appropriate post-fall assessments, including timely vital signs and neurological checks, for a resident who experienced two falls on the same day. The resident had multiple significant diagnoses, including dementia, pancreatic cancer, atrial fibrillation, history of falls, hypotension, and other comorbidities, and required supervision or touching assistance for toileting and bathing per the most recent MDS. The resident was care planned as being at risk for falls related to forgetfulness, history of falls, unsteady gait/poor balance, and multiple medications. Despite this identified fall risk, the facility did not ensure that post-fall assessments were fully and accurately completed and documented.

For the first fall on 12/31, the facility’s internal form showed the fall occurred at approximately 10:45 a.m., but the SBAR documented at 12:00 p.m. did not specify the time of the fall. The vital signs recorded on the SBAR for this morning fall were taken at 9:14 a.m., 10:07 a.m., and 12:08 p.m., which the DON confirmed were obtained before the fall occurred. The DON verified there were no vital signs or neurological checks documented at the actual time of the fall, and no neuro check documentation was provided for this first fall. The DON also confirmed that, although the resident herself was notified, the family should have been notified and there was no indication that this occurred for the morning fall. The resident later reported having found and taken a pink pill (Benadryl) from the floor, and the DON stated staff looked at the resident’s floor but did not find anything and could not recall if other rooms were checked.

For the second fall that evening, staff documentation and interviews showed that the resident was found on the floor with a small amount of blood and a raised open area on the back of the head. Staff B, LPN, documented returning from lunch and being informed by staff that the resident was on the floor, finding her lying on the floor with a head wound, cleansing the area with normal saline, and applying a bandage. The resident was able to move extremities on command and complained of slight ankle pain and chronic shoulder pain. An SBAR for this evening fall documented vital signs taken after the fall and indicated that the primary care clinician was notified and that staff were awaiting a call back; however, the DON verified there was no documentation that the provider ever called back or that any follow-up discussion occurred, despite the resident having hit her head. Neurological checks were documented as starting at 10:10 p.m. on 12/31 and continuing until 01/03 on the day shift, but there was no neuro check documentation tied to the first fall at approximately 10:45 a.m. Staff interviews were inconsistent about the timing and sequence of the falls, and the DON confirmed that the expectation was to see neurological checks after the first fall and clear documentation of provider communication, which were not present.

The facility’s own policies required timely physician notification and documentation for accidents or incidents involving residents and for significant changes in condition, as well as individualized fall management and documentation for residents who experience falls. The policy on change in condition required the nurse to notify the attending physician when there was an accident or incident involving the resident and to record information related to changes in the resident’s condition in the medical record. The falls policy required that residents who experience a fall have appropriate documentation completed. In this case, the surveyors found that for one resident with a known fall risk and complex medical history, the facility failed to obtain and document vital signs and neurological checks at the time of the first fall, failed to clearly document the time of the fall on the SBAR, and failed to document follow-up communication with the medical provider after the second fall in which the resident hit her head, resulting in incomplete post-fall assessment and monitoring.