F0689

D

Failure to Provide Hands-On Assistance With Ambulation Resulting in Resident Fall and Head Injury

Cando, North Dakota Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide adequate supervision and hands-on assistance with ambulation to prevent accidents for a resident identified as being at risk for falls. The facility’s Fall Prevention Policy stated that each resident would be assessed for fall risk and receive care and services according to their individualized level of risk to minimize the likelihood of falls. For this resident, the facility-reported incident (FRI) documented that a CNA called an RN to the bathroom, where the RN found the resident on the floor with a quarter-sized open flap wound to the right posterior head and active bleeding. The RN’s note indicated the CNA stated she was walking the resident to the toilet when the resident’s right ankle twisted, causing her to fall and hit her head on the countertop.

In contrast, the resident consistently reported to multiple staff, including a social worker, that the CNA had applied a gait belt and opened the bathroom door but did not walk into the bathroom with her, remaining instead in the bedroom by the recliner. The resident stated she walked to the bathroom alone, attempted to catch her balance, but was unable to do so and struck her head on the countertop, describing that she “really cracked it.” She also reported that other CNAs typically “hold onto” her when she walks to the bathroom. Nursing progress notes documented the head injury, the resident’s alert status, orientation to what happened, and pain at the wound site without headache. An administrative staff member stated an expectation that staff ensure residents receive adequate assistance and that staff follow the resident’s care plan, underscoring that the resident did not receive the hands-on assistance with ambulation that was required at the time of the fall.