F0689

D

Failure to Assess, Monitor, Document, and Report an Unwitnessed Fall With Head Impact

Jackson, Mississippi Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own fall policy and adequately assess, monitor, and report an unwitnessed fall with head impact for one resident. The facility’s Falls Standard policy required that when a resident is found on the floor, staff must investigate the reason for the fall, obtain vital signs while the resident is on the ground, perform neurological checks for unwitnessed falls or head injuries, and complete fall-related documentation including a Fall Risk Assessment, incident report, and post-fall investigation. The policy also required neurological assessments every 15 minutes for 2 hours, every 30 minutes for 2 hours, and then every shift for 72 hours, as well as timely notification of the resident’s primary healthcare provider, resident representative, DON, and others as appropriate. These procedures were not followed after the resident’s fall on the evening of 12/27/25.

Resident #1 was admitted with diagnoses including paraplegia, reduced mobility, and lack of coordination, and was documented as non-ambulatory and dependent for transfers. The resident was cognitively intact with a BIMS score of 14. On the evening of 12/27/25, the resident fell from the bed while reaching for something on the floor and struck her head, resulting in a bump and swelling on the right forehead. CNA #1 and CNA #2 reported finding the resident lying on her face on the floor next to the bed at approximately 7:45–7:48 PM, and stated that an LPN instructed them to assist the resident back into bed. There was no documentation of a fall, no recorded vital signs taken while the resident was on the floor, and no neurological checks, pain assessments, or body/skin audits performed or documented during the 3:00 PM–11:00 PM or 11:00 PM–7:00 AM shifts following the incident.

The fall was not reported to supervisory staff, the primary healthcare provider, or the resident representative at the time it occurred. The resident later informed the Wound Care Nurse on the morning of 12/28/25 that she had fallen the previous evening, hit her head on the floor, and had swelling and tenderness above the right eye. Only after this self-report were the Unit Manager, DON, primary healthcare provider, and resident representative notified, and an incident report and investigation initiated. The resident representative stated she was not notified of the fall until the following morning and expressed disapproval and disappointment with the delay in notification, noting that the resident had a bump on her forehead and had not received assessments or treatment until the next day. The Administrator and DON confirmed there was no documentation of the fall or appropriate assessment or evaluation on the evening and night shifts, and that nursing staff did not follow the facility’s fall policy, including required assessments, monitoring, documentation, and timely notification of the resident representative and primary healthcare provider.

The DON acknowledged that the correct procedure after a fall included immediate assessment, body/skin audit, pain assessment, initiation of neurological checks and vital sign monitoring for 72 hours, and prompt notification of the primary healthcare provider, resident representative, DON, Administrator, and ambulance if needed. The DON also confirmed that failure to report incidents and provide assessments and care according to the fall policy could result in the resident having unrelieved pain, complications, or negative unidentified results from falls. Interviews with the Unit Manager and Wound Care Nurse further confirmed that falls were to be reported and documented on the 24-hour report, with incident reports and ongoing assessments, and that resident representatives should be notified right away as a change of condition. Despite these established policies and staff knowledge, the required post-fall assessments, monitoring, documentation, and timely notifications were not carried out following Resident #1’s unwitnessed fall with head impact on the evening of 12/27/25.