F0658

D

Failure to Immediately Assess and Document Resident After Witnessed Fall During Mechanical Lift Transfer

West Plains, Missouri Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure staff followed professional standards of practice by not immediately assessing a resident after a witnessed fall and not documenting a timely post-fall assessment. The facility’s Falls – Clinical Protocol required that residents who fall be assessed for injury at the time of the fall, with nursing assessment and documentation of vital signs, injury, musculoskeletal function, cognition, neurological status, pain, and details of the fall. The protocol also required assessment and charting for 72 hours and notification of family for all falls. Despite these requirements, there was no documentation of a post-fall assessment or post-fall skin assessment for the resident on the date of the incident.

The resident involved had an admission date of 11/16/22 and diagnoses including arthritis, non-Alzheimer’s dementia, anxiety disorder, muscle weakness, and a history of falling. The resident’s MDS showed severely impaired cognition and dependence on staff for all ADLs and transfers, and the care plan identified the resident as at risk for falls due to weakness, impaired vision, dementia, medications, inability to stand, agitation, restlessness, and poor safety awareness. The care plan also specified use of a Hoyer lift for transfers. On the day of the incident, staff used a portable ceiling lift to transfer the resident after a shower. CNA A reported that the lift broke and the resident began to drop, so CNA A grabbed the resident, pulled the resident toward his/her chest, and slid the resident to a seated position on the floor, resting on the CNA’s feet. CNA B entered the room and observed the resident seated on the floor in front of CNA A.

CNA A and CNA B did not immediately notify the nurse of the fall because they did not feel the resident was injured and believed the nurse was busy. Instead, they assisted the resident from the floor to a Geri chair using a gait belt and a fireman lift without a prior nursing assessment. This action was contrary to the expectations described by multiple staff and leadership interviews, which stated that when a resident falls or is found on the floor, the nurse should be called immediately, the resident should not be moved until assessed by the nurse, and only the nurse should perform the post-fall assessment. Although the incident report and progress notes indicate that RN C later entered the room and performed a head-to-toe assessment with no injuries noted, there was no corresponding progress note documenting this assessment or a detailed description of the incident on that date, and there was no documented post-fall skin assessment. Later that day, staff reported bruising and discomfort in the resident’s right lower extremity, leading to physician notification and orders for x-rays, but the initial failure to immediately notify the nurse, perform, and document a timely post-fall assessment constituted the cited deficiency.