F0689

G

Unsupervised Dining Room Leads to Unwitnessed Fall and Shoulder Fracture

Cedar Rapids, Iowa Survey Completed on 01-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and maintain an accident‑hazard‑free environment in the dining room, resulting in an unwitnessed fall and fracture for one resident. The resident had severe cognitive impairment, a history of falls with fracture within the prior six months, and multiple diagnoses including fractures, hypertension, diabetes, and dementia. Care plans identified the resident as at risk for wandering and falls, required substantial/maximal assistance for transfers with a mechanical lift, use of a wheelchair for mobility, and continuous use of a left upper extremity immobilizer. The care plans also documented a prior facility fall on 11/3/2025 when the resident slid out of bed, and fall risk evaluations on 10/22/2025 and 11/28/2025 confirmed the resident was a fall risk.

On the day of the incident, the resident was in the dining room in a wheelchair during the noon meal. Two staff members, a CNA and a medication aide, were present in the dining room assisting residents with eating and passing medications. Another resident in the dining room was reportedly refusing to eat and “not acting right,” prompting staff to call an LPN from upstairs to assess that resident. The LPN came to the dining room, observed the two staff assisting residents, and told them to lay the other resident down. Accounts differ on timing and interpretation: the CNA and medication aide reported they understood this as an immediate directive and left the dining room with the other resident, while the LPN stated she meant for the lay‑down to occur when staff did their regular lay‑downs and that the residents in the dining room should have been removed or one staff member should have remained.

When the CNA and medication aide left the dining room, residents were still eating and no other staff remained in the room. The two staff took the other resident to her room, transferred her to bed using a stand‑up lift, and provided cares, which took approximately 8–15 minutes. During this period, the dining room was unsupervised. While they were away, a male resident witnessed the cognitively impaired, fall‑risk resident fall but was unable to intervene. Upon returning, staff found the resident on the floor on her right side with the wheelchair nearby; she had been seated at a table in her wheelchair when they left. The resident had a hematoma to the right forehead, right shoulder pain, and later imaging in the ED showed an acute fracture of the distal tip of the right acromion of the right scapula. The facility administrator and ADON later confirmed that residents in the dining room were expected to be under supervision while eating and that there was no specific written policy for dining room supervision at the time of the incident.

The facility’s self‑report and subsequent interviews confirmed that the fall was unwitnessed and occurred in the dining room shortly after lunch, during a period when no staff were present. The resident, who was unable to provide a reliable history due to dementia, was found seated upright on the floor with legs extended and guarding her right shoulder. The ED documentation noted the unwitnessed fall, right forehead hematoma, right shoulder pain, and contusion to the right side of the face, with imaging confirming the right scapular fracture and no acute intracranial or spinal injury. Staff interviews consistently indicated that facility expectations had been communicated verbally or in meetings that at least one staff member should remain in the dining room when residents were present and eating, but on the day of the incident, both staff assigned to the dining room left simultaneously, leaving the resident and others unsupervised.

The report also describes the sequence of clinical assessment and diagnostic imaging following the fall. After the incident, the LPN obtained orders for cervical spine and right shoulder X‑rays and contacted the portable X‑ray company, which initially indicated same‑day availability. When the company later could not come until several days later, the resident was sent to the ED for urgent evaluation due to increased pain. The ED confirmed the right scapular fracture and the resident returned with a right arm sling. Nursing staff on subsequent shifts were aware that the resident was awaiting imaging and reported that the resident was sleeping and did not recall complaints of pain during their checks, but the documentation and ED findings confirmed that the resident had sustained a significant injury as a result of the unwitnessed fall in the unsupervised dining room.