F0689

D

Failure to Complete Post-Fall Assessments for Two Residents at Risk for Falls

Richmond, Indiana Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete required post-fall assessments for two residents identified as being at risk for falls. Resident B had diagnoses including dementia, repeated falls, Alzheimer’s disease, vitamin D deficiency, and bone density disorders, and used a wheelchair for mobility. The resident’s care plan identified multiple fall risk factors, and no new interventions had been implemented since 4/27/23. A change in condition note documented that Resident B was exhibiting paranoid and aggressive behaviors and was sent to the hospital via EMS, but there was no documentation of a fall or any post-fall assessment associated with that event.

Resident B later reported having fallen near the nursing station about three weeks prior to the interview, stating she lost her balance and that 2 or 3 staff witnessed the fall. One CNA reported witnessing Resident B attempt to stand from her wheelchair when an RN pushed her down, causing the resident to fall to the floor, and stated that the RN instructed staff not to say anything about the incident. Another CNA reported that on the same date, during behavioral outbursts, the RN grabbed the resident’s wheelchair and the resident fell, and that the RN told staff not to help the resident; the CNA stated that another CNA assisted the resident back into the wheelchair. This CNA also reported the incident to the Unit Manager. The RN involved stated she did not think the resident had fallen and did not document or assess a fall. Another nurse reported that she only learned of the fall weeks later from a CNA and that there was nothing in report about a fall.

Resident C had generalized anxiety disorder, was cognitively intact, used a wheelchair, and required assistance with bed mobility and transfers. A fall risk evaluation identified the resident as at risk for falls. A progress note documented that staff responded to the resident yelling out and found her lying on the floor against the wall, crying out in pain with her left leg, and that the physician was notified and the resident was sent to the ER. A facility-reported incident stated that the resident told staff she fell while attempting to get out of bed and that she was evaluated by a nurse and sent to the hospital. A hospital discharge summary documented that the resident sustained a mechanical fall resulting in a closed hip fracture and underwent surgery with nail and screw placement. The DON confirmed that although there was an IDT note about the fall, no post-fall assessment was completed for this resident, despite facility policy requiring assessment and completion of a post-fall assessment, including documentation of all assessments and actions, after any resident fall.