Failure to Assess, Document, and Report Resident Fall and Resulting Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and post-fall procedures for a resident at high risk for falls. The facility’s Fall Prevention Program policy required that when any resident experiences a fall, staff must assess the resident, complete a post-fall assessment and incident report, notify the physician and family, review and update the care plan as indicated, document all assessments and actions, and obtain witness statements in the case of injury. Resident #2, admitted with heart failure, polyneuropathy, bone density disorders, protein-calorie malnutrition, and anemia, had moderate cognitive impairment and required substantial to maximal assistance with mobility and toileting. The resident’s care plan identified them as high risk for falls due to impaired mobility and poor safety awareness. Staff interviews and the facility’s own incident investigation revealed that the resident fell from bed at approximately 6:00 AM on 12/10/2025. Following this fall, RN #21 (also referenced as RN #2 in interview) stated she looked at the resident and did not observe any injuries but did not complete any of the required fall-related documentation, including the incident report, post-fall assessment, or documentation of the fall itself. She also stated she was not sure she reported the fall to anyone on the oncoming shift, and there was no evidence that the physician or responsible party were notified at that time. GNA #22 reported to RN #21 that the resident’s leg was “wobbly” on the morning of the fall and later asked a CMA to help place the resident back in bed, telling the CMA that the nurse had already assessed the resident. No pain was reported at that time. The next day at 6:00 AM, another RN noted swelling, pain with movement, purplish discoloration, and abrasions on the resident’s left lower leg and ankle. Later that morning, an LPN observed that the ankle appeared abnormal and discolored, requested a physician evaluation, and the resident was sent to the ER, where imaging showed a comminuted fracture of the distal tibia and fibula. The DON and Administrator both confirmed that the expected process—assessment, documentation, and notification of the provider, responsible party, and oncoming staff—was not followed for the 12/10/2025 fall.
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