F0689

J

Failure to Implement Timely Post-Fall Assessment and Interventions After Repeated Falls

Georgetown, Texas Survey Completed on 01-09-2026

Penalty

Fine: $73,260

Summary

The deficiency involves the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents for a cognitively impaired male resident with significant mobility and neurologic deficits. The resident had a history of right-sided hemiplegia/hemiparesis following a stroke, aphasia, muscle weakness, gait and mobility abnormalities, dysphagia, unsteadiness on his feet, and used a wheelchair. His care plan identified him as at risk for falls, with interventions such as keeping the call light within reach, educating him about safety reminders, and re-educating him to lock wheelchair brakes prior to transfers. Assessments showed he required varying levels of assistance for transfers and mobility and had moderate to severe cognitive impairment, yet he was often treated as mostly independent in transfers and ambulation.

On or about early December, the resident experienced an unwitnessed fall near his bed at night. A CNA found him on the floor by the bed, with his feet under the bed, apparently having fallen while trying to transfer to his wheelchair. The CNA notified the LVN, who assessed the resident, took vital signs, administered PRN tramadol for reported pain, and assisted him back to bed. However, the LVN did not notify the NP, MD, DON, responsible party, or administration, did not initiate neurological checks despite the fall being unwitnessed, and did not complete an incident report or timely documentation of the fall. A late entry note documenting the fall was not entered until 12/17, and there was no evidence of post-fall monitoring, neurological assessments, or new fall-prevention interventions being implemented after this initial fall. Staff later reported that the resident became more withdrawn, stopped going to the dining room, and changed his usual routine, but these changes were not documented or communicated as potential signs of injury or change in condition.

Subsequently, the resident sustained another unwitnessed fall near the bathroom when he missed sitting on his wheelchair after using the bathroom. This second fall was reported to the NP and responsible party, and neurological checks were initiated, but the only documented intervention was to encourage the resident to use the call light or ask for assistance—an intervention that was already in place prior to the fall. A therapy evaluation was not ordered until several days after the second fall, and there was no evidence of immediate, enhanced fall-prevention measures or increased monitoring following either fall. Radiology studies ordered after the delayed recognition of bruising and pain revealed multiple areas of soft tissue swelling and ultimately a nondisplaced fracture of the greater trochanter of the right proximal femur, requiring surgical repair. Interviews with multiple staff, including CNAs, LVNs, the RN, DON, ADM, DOR, and NP, confirmed that facility policy required immediate assessment, neurological checks for unwitnessed falls, timely incident reporting, and prompt notification of providers, DON, and family after any fall, as well as 72-hour monitoring and review for new interventions. These required actions were not carried out after the first fall, and new or enhanced interventions were not promptly implemented after either fall, leading to the identified deficiency.

The facility’s own staff acknowledged that the resident’s functional status declined after the first fall, with increased need for assistance and incontinence, yet this change was not linked to a documented fall event or followed by appropriate reassessment and care plan revision. The DON and ADM both stated that they were not informed of the initial fall until days later and that interventions were not added until after the delay. The NP reported that she discovered bruising and swelling on the resident’s arm and noted his withdrawal and pain before any fall had been reported to her, and she ordered x-rays based on her findings rather than on timely fall notification. Review of facility policies and staff interviews showed that the expected fall protocol—immediate assessment, neurological checks for unwitnessed falls, incident reporting, timely notification, and prompt implementation of individualized interventions—was not followed for this resident, resulting in delayed identification and treatment of injuries and failure to implement timely, effective fall-prevention measures after repeated falls.

Removal Plan

• Effective immediately, all licensed nursing staff including PRN, Agency and New Staff will be in-serviced by the Director of Nursing (DON) and Administrator (ADM) on the facility's Fall Prevention Policy, emphasizing mandatory post-fall assessments including neurological checks, vital signs monitoring, and timely notification of providers and administration for every fall.
• Orientation for all new hires will include Fall Prevention Policy training before assuming duties.
• Facility Administrator and DON will be in-serviced on the Risk Management protocol by the Area Director of Operations and Regional Compliance Nurse.
• The facility will implement a fall follow-up protocol requiring the nurse assigned at the time of the fall to complete a detailed incident report immediately and document all neurological and vital signs assessments in the resident's medical record within the same shift.
• The DON or designee will ensure consistent compliance with the fall follow-up protocol.
• The interdisciplinary team including the DON, Medical Director, and Therapy Director will review and update Resident #1's care plan to incorporate individualized fall prevention interventions tailored to his multiple fall risks and clinical status, including frequent monitoring, assistance with transfers, and immediate post-fall interventions.