Failure to Implement Required Post-Fall Evaluations After Unwitnessed Fall
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice by not implementing required post-fall evaluations for one resident. The resident was admitted with diagnoses including sepsis, muscle weakness, and gait and mobility abnormalities, and required substantial to maximal assistance with multiple ADLs, including transfers and positioning. A fall risk assessment indicated the resident was a low fall risk, cognitively intact, and used a walker or wheelchair. A progress note documented that during room checks on 12/18/2025 at 1:05 PM, a nurse found the resident on the floor beside the bed after the resident reported slipping while trying to push herself back into bed. The nurse documented a head-to-toe assessment noting a red mark on the forehead and a skin tear on the left elbow, and that a mechanical lift was used with a CNA to return the resident to bed. Record review showed no neurological checks or other fall-related assessments following this unwitnessed fall, despite the presence of a red mark on the resident’s forehead and a skin tear. During interviews, the ADON, DON, and NHA acknowledged the fall was unwitnessed and that the facility did not ask the resident if the red mark on the forehead was due to a head injury, instead accepting the resident’s explanation. The ADON stated they did not know the cause of the red mark and confirmed that no neuro checks were found in the record. The DON stated that unwitnessed falls require monitoring, neuro checks, complete skin assessments, treatment for possible skin care, frequent monitoring, and range of motion assessments, and acknowledged these required post-fall steps were not completed. Review of the facility’s Fall Management policy showed that post-fall strategies must include resident evaluation, initiation of neurological checks, physician and representative notification, post-fall evaluation, care plan updates, 72-hour post-fall documentation, IDT review with root cause analysis, and weekly review, which were not implemented for this resident after the fall.
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