F0609

D

Failure to Report Serious-Injury Falls and Inadequate Fall Investigation for Two Residents

Minneapolis, Minnesota Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely report to the State Agency falls with serious injury for two residents and to conduct adequate fall investigations and care planning. One resident with Parkinson’s disease, congestive heart failure, atrial flutter, and diabetes was assessed as a moderate fall risk and required substantial assistance with transfers, toileting, and some ADLs, but the admission assessment lacked a cognitive assessment and a baseline care plan was not initiated until after the resident had already been transferred to the hospital. The resident experienced an unwitnessed fall in the early morning, was found on the floor with her head on a pillow, and was documented as having no injury, with neuro checks and vital signs completed. The incident report did not include a comprehensive fall investigation or analysis of causal factors, including the absence of care plan interventions to direct staff on the level of assistance needed for ADLs.

Hospital emergency department records later showed that this resident sustained an acute superior endplate compression fracture of T12 with burst-type morphology and slight bony retropulsion, requiring pain management, a spinal brace, and physical therapy. The resident’s family member reported that the resident stated she had been on the floor for several hours before being found, and that the family member called 911 to transfer the resident to the hospital, where the spinal fracture was discovered. The LPN who found the resident on the floor was unable to state when the resident was last checked and could not articulate how the resident was supposed to transfer or what fall-prevention interventions were to be used. The administrator later stated that this fall was not reported to the State Agency because it was considered explainable and not an allegation of abuse, and the administrator was unaware that the resident’s MDS had been coded as a fall with major injury based on hospital information.

The second resident had diagnoses including hemiplegia and hemiparesis following stroke, epilepsy, Charcot joint of the left ankle and foot, and dizziness, and had severe cognitive impairment and dependence in most ADLs. This resident had multiple prior falls where dizziness was repeatedly identified as a causal factor, but records lacked monitoring of dizziness and comprehensive assessments to identify individualized fall-prevention strategies. The resident then had an unwitnessed, self-reported fall in the bathroom during a self-transfer after toileting, resulting in left knee swelling and significant pain; an x-ray later showed a comminuted fracture of the left tibial plateau, and the resident was hospitalized for worsening leg/knee pain with displaced and impacted intra-articular fractures. The administrator stated that this fall also was not reported to the State Agency after knowledge of the serious injury because it was considered explainable and not an allegation of abuse, despite facility policy directing that events resulting in serious bodily injury must be reported to the State Agency.