F0658

D

Failure to Assess and Document Care After Unwitnessed Fall

Braintree, Massachusetts Survey Completed on 01-15-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality following an unwitnessed fall. A resident with a history of a fall resulting in a subdural hematoma requiring a right craniotomy, Parkinson’s disease, and anticoagulation use was admitted in 10/2025. On 10/27/25 at approximately 7:15 A.M., the resident was found on the floor next to the bed by one nurse (Nurse #2), who then notified the assigned nurse (Nurse #1). Both nurses assisted the resident back into bed. Facility policy required that any fall, including unwitnessed falls, be followed by physician and family notification, completion of a fall incident report and fall investigation, monitoring of vital signs, and neurological checks.

Nurse #1 reported that, because it was the end of her shift and Nurse #2 told her not to worry about the documentation, she did not obtain vital signs, did not perform neurological checks, and did not complete any fall, skin, or pain assessments, incident report, or timely nursing progress note for the event, only entering a late note on 11/04/25. Nurse #2 stated she assumed Nurse #1 would complete the required documentation and did not follow up or report the incident to anyone that day, only mentioning it the following morning in report. The Staff Development Coordinator and DON both stated they were not aware the resident had been found on the floor on 10/27/25 until a bruise of unknown origin was identified by the resident’s health care proxy on 10/28/25, and both confirmed that the facility’s expectation is that the responding nurse immediately assess the resident and complete all required assessments, vital signs, neurological checks, and notifications after any witnessed or unwitnessed fall.