F0600

D

Failure to Report and Assess Unwitnessed Fall Resulting in Resident Neglect

Lake Isabella, California Survey Completed on 12-17-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from neglect when a Charge Nurse intentionally did not report, document, or properly assess an unwitnessed fall. The resident had moderately impaired cognition with a BIMS score of 11 and was documented as having upper and lower extremity impairments, requiring total assistance for bed-to-chair transfers. On the day of the incident, a behavior note documented that the Charge Nurse found the resident attempting to get out of bed, talking about playing a game with her boys and getting a dog, and then later documented that the resident was found sitting naked on the floor, confused, hallucinating, and talking about playing a game with her boys and eating toes. The resident was dressed, placed in a Geri-chair, and positioned near the nursing station for observation, but the contemporaneous documentation did not show that a fall assessment, vital signs, or neuro checks were completed at that time.

A later nursing note by another LVN, entered that evening as a late entry, indicated that CNAs had informed her that the resident had been found on the floor naked and hallucinating earlier in the day, and that she then notified the DON, the physician, and the resident’s son, completed unwitnessed fall documentation, a skin assessment, and vital signs, and noted a new bruise on the resident’s right forearm. Neuro/vital sign flow sheets showed that the first neuro checks were not initiated until the early evening, several hours after the initial fall event. Another late entry nursing note, authored by the Charge Nurse days later, stated that the Charge Nurse had found the resident calmly sitting on the floor next to the bed, unclothed and playing a game with her boys, that the resident denied falling twice, was assessed with no injury noted, denied pain or discomfort, and was lifted into a Geri-chair and placed by the nursing station. This late entry note also stated that the Charge Nurse did not report the event as a fall to a supervisor and did not complete a fall form at the time because she did not believe the resident had actually fallen.

Multiple CNAs reported that they observed the resident on the floor and assisted in moving the resident without seeing the Charge Nurse perform an assessment or ask the resident questions. One CNA stated that the Charge Nurse instructed them to help lift the resident into the Geri-chair and did not assess the resident before or after moving her, and that the resident was totally dependent for care and could not have gotten to the floor and sat there on her own. This CNA reported that the Charge Nurse told the CNAs not to say anything, and she felt this was neglect. Another CNA stated that the Charge Nurse said this was the second time the resident had been found on the ground, did not perform an assessment or take vital signs, and told the CNAs not to say a word about the incident; this CNA had given the resident a shower earlier and noted no skin issues at that time. A third CNA, who initially found the resident on the floor without a gown, reported the fall to the Charge Nurse, helped dress the resident and transfer her to the Geri-chair, and also stated that the Charge Nurse did not ask questions or take vital signs and told the CNAs not to say anything about the fall. The Charge Nurse later acknowledged that she did not complete vital signs or neuro checks at the time of the incident, did not document the late entry note until a couple of days later, and stated that she told the CNAs she was not reporting it as a fall. The facility’s abuse prevention policy defined neglect as the failure of the facility or its employees to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and the resident’s care plan later identified a focus on potential for neglect related to unwitnessed falls, including interventions that all necessary documents would be completed and staff would report any unwitnessed falls.