F0610

E

Incomplete Investigation and Documentation of Resident Falls

New Rochelle, New York Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly investigate and completely document alleged violations related to resident falls, contrary to its Accident/Incident Reporting policy and 10 NYCRR 415.4(b)(1)(ii). For one resident with dementia, bipolar disorder, severe cognitive impairment, lower extremity impairment, wheelchair use, and a history of multiple falls, an unwitnessed fall occurred. The accident/incident report lacked the time of supervisor notification and did not document whether the physician or family representative were notified. The CNA statement did not include the time the resident was last seen and incorrectly documented that the resident used alarms, despite the record indicating no bed, chair, floor mat, or motion sensor alarms. The post-occurrence investigation conclusion form dated the next day had its section titled “Steps taken that led to conclusion of investigation” left blank by nursing administration.

For a second resident with sequelae of cerebral infarction, seizures, and left-sided hemiplegia who was cognitively intact and required supervision for ADLs but had no prior fall history, the resident’s representative called to report that the resident had fallen. The RN documented that staff immediately went to the room and found the resident in bed, with the resident reporting they had slid off the bed and gotten up independently, denying head impact and pain. The accident/incident report did not include documentation of physician notification and had no staff statements attached. A CNA occurrence statement completed two days later omitted the time of occurrence and the CNA’s name. The post-occurrence investigation report documented that the resident’s site of injury was re-assessed, despite there being no documented evidence in the accident/incident report that the resident sustained any injury. The post-occurrence investigation conclusion was not signed and dated by the Administrator.

For a third resident with dementia, Parkinson’s disease, and a history of falling, staff found the resident lying on the floor on their back to the left side of the bed. The resident was assisted back to bed by three staff members and assessed, with an abrasion noted on the right outer back, denial of head impact and pain, and normal range of motion in all extremities. The accident/incident report, however, documented that no injuries were observed at the time of the incident, despite the abrasion being recorded elsewhere in the same report. Interviews with the DON and Administrator confirmed that required elements such as staff statements, times, notifications, and completion and signing of investigative conclusions were missing or incomplete, and an RN acknowledged that documenting “no injury” despite an abrasion was an error.