F0684

D

Failure to Monitor and Treat Change in Condition After Post-Surgical Fall With Head Impact

Twinsburg, Ohio Survey Completed on 01-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely monitor and treat a resident’s change in condition following a fall with head impact. The resident had been admitted after cervical spine surgery (C3–C9 laminectomy and fusion) with diagnoses including cervical spinal stenosis, fusion of the cervical spine, fibromyalgia, muscle weakness, need for assistance with personal care, and lack of coordination. The care plan identified a decline in functional abilities and mobility related to recent surgery and specified that nursing should provide skilled services per physician orders, assist with mobility, and monitor for changes in condition or declines in ability, strength, or cognition, with physician notification if such changes occurred. The resident also had a care plan for pain that required pain assessment every shift, assessment for non-verbal indicators of pain, use of non-pharmacological interventions, and positioning for comfort.

On the day of the fall, the resident attempted to use the bathroom without assistance and was found on the bathroom floor lying on her back with her walker in front of her. She reported that she had tried to use the bathroom without help and had hit her head on the wall before falling. Nursing staff assessed her and noted no visible injury but documented that she complained of dizziness, nausea, and vomited twice. The NP evaluated the resident, initiated neuro checks, ordered IV normal saline and Zofran, and decided to treat the resident in-house rather than send her to the ER, despite the primary nurse’s initial desire to send her out. The surgeon’s office, when contacted after the fall, stated that if there were any new changes after the fall, the resident should be sent to the ER, but left the determination to the facility. Staff interviews confirmed that after the fall the resident repeatedly complained of dizziness and vomited multiple times, and that when attempts were made to sit her up from the floor she would vomit and had to be laid back down.

The facility’s monitoring and documentation after the fall did not follow ordered protocols or the resident’s care plan. The 72-hour neuro assessment flow sheet ordered after the fall required neuro checks at frequent intervals (every 15 minutes, then every 30 minutes, then hourly, then every 4 hours), but the DON confirmed that neuro assessments were not completed at the required times; there was a gap between a 3:00 p.m. assessment and the next at 7:00 p.m., and then not again until 2:00 a.m. The DON also confirmed there was no documentation of changes in condition after the fall other than vomiting, despite staff reports of dizziness and positional neck pain. The medical record, including the MAR and TAR, contained no evidence that the resident was monitored for pain every shift as required by the care plan, and there was no documentation of non-pharmacological pain interventions post-fall. Staff, including the RN and CNA who cared for the resident, reported that after the fall the resident had a new pattern of neck pain that occurred when sitting up and resolved when lying down, which they had not observed before the fall. Several days later, the resident was transported to the ER, where a CT scan of the cervical spine showed findings concerning for a fracture adjacent to the C3 screw and possible backing out of hardware at C3, with surgical evaluation suggested.

Interviews with the resident’s daughter revealed that the resident had been admitted with a neck brace after surgery, which the surgeon later allowed to be removed, and that after the fall the daughter was told there had been debate among staff about sending the resident to the hospital. The daughter stated that when she visited days later, the resident complained of dizziness and neck pain, and the daughter then insisted on hospital transfer, after which multiple neck fractures were identified. The NP confirmed she was aware of the resident’s vomiting and dizziness after the fall, performed a neuro exam she considered normal, ordered neuro checks and Zofran, and recommended the resident stay in the facility, stating she left the decision to the resident, who reportedly declined hospital transfer. The NP acknowledged she did not speak with the daughter after the fall and stated that staff did not report further changes in condition to her. The facility’s own policy on change in condition required prompt notification of the resident, attending physician, and resident representative of changes in medical or mental condition or status, but the record and interviews showed gaps in monitoring, documentation, and communication following the resident’s fall and subsequent change in condition.