F0658

D

Failure to Assess Change in Behavior and Perform Required Post‑Fall Assessment

Oakhurst, California Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure nursing services met professional standards of quality and to follow its policy titled “Nursing Assessment and Management of Residents Following a Fall” for one sampled resident. The resident was admitted with a history of falling, anxiety disorder, dementia, and a cognitive communication deficit, and had a BIMS score of 5/15 indicating severe cognitive impairment. On the day in question, CNAs observed that the resident was restless, anxious, exit seeking, self‑propelling in her wheelchair through the halls, and attempting to get into other residents’ beds, which both CNAs identified as behavior that was out of her normal pattern. Despite this change in behavior, LVN 1 did not perform an assessment to determine the cause of the behavior and did not notify the physician for guidance. Instead, LVN 1 instructed CNA 1 and CNA 2 to assist the resident to bed, even after both CNAs expressed concern that putting the restless resident in bed could lead to a fall.

After the CNAs assisted the resident to bed, they observed her awake and fidgeting with the bed remote and call light. Approximately 15–30 minutes later, CNA 1 and CNA 2 found the resident sitting on the hallway floor outside her room. Both CNAs reported that LVN 1, who was in the hallway, directed them to pick the resident up from the floor and assist her back to bed before LVN 1 completed an assessment for injuries. CNA 1 and CNA 2 stated that the facility process required the nurse to assess a resident for injuries before the resident was moved or transferred after a fall. LVN 1 later acknowledged that the resident’s behavior had been different that day, that no assessment was completed to identify the cause of the behavior before the fall, and that she did not assess the resident while the resident was still on the floor following the unwitnessed fall.

Documentation reviewed by surveyors showed that the progress note for that day recorded the resident as being found on the ground in her room, sitting upright near the foot of her bed, and noted that she had been self‑propelling through the halls and attempting to lie in other residents’ beds. An SBAR form documented an unwitnessed fall with no injuries noted and described the resident as anxious and requiring redirection throughout the shift. LVN 1 stated she only completed a quick, limited assessment after the resident was already back in bed, focusing on visible skin, vital signs, and observation of extremity movement, and did not perform a thorough head‑to‑toe assessment as required by facility policy. The facility’s fall policy required an immediate, comprehensive post‑fall assessment, including a head‑to‑toe physical and neurological assessment, and specified that residents should not be moved until assessed unless remaining in place posed immediate risk. The DON and DSD both confirmed that the facility’s expectation was for the nurse to assess residents when there was a change in behavior and immediately after a fall, and that the nurse should assess the resident on the floor before any transfer.

On the following day, a progress note documented that the resident was observed in a wheelchair in the lobby with a bruise on the top of the left outer palm and top of the left hand, which had not been identified on the day of the fall. An x‑ray order was obtained for the left hand and wrist related to the unwitnessed fall, and the radiology report showed a fracture of the 5th metacarpal shaft with associated soft tissue swelling. A subsequent SBAR documented that the radiology company reported a fracture to the left hand and that this injury was a delayed finding after the unwitnessed fall. The hospital emergency department record noted bruising and purple discoloration to the left hand and referenced the ground‑level fall the previous day. These findings demonstrated that the resident sustained an injury that was not identified at the time of the fall due to the lack of timely, thorough assessment in accordance with professional standards and the facility’s post‑fall policy.