F0684

G

Failure to Recognize and Respond to Resident’s Post-Fall Change in Condition

Fremont, Michigan Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly identify and act upon a resident’s change in condition following an alleged fall, resulting in delayed medical treatment for significant pelvic and sacral fractures. The resident was an older female admitted with existing sacral and pelvic fractures from a prior fall and Parkinson’s disease, and was cognitively intact with a BIMS score of 13. Her Kardex indicated she required one-person assist with a gait belt and walker for stand-pivot transfers and that staff were to report changes in normal behavior and decline in ADLs and continence. On the date of the alleged incident, a family member later reported that the resident told him she fell in the shower and that the aide told her not to tell anyone. The family member identified the aide as a specific CNA, who denied involvement or knowledge of a fall. There was no documentation in the EMR that this CNA notified licensed staff or management of a fall allegation on that date.

Over the next several days, multiple changes in the resident’s condition occurred without appropriate assessment, documentation, or escalation. The family member observed that the resident had increased pain over the weekend and later increased confusion. A CNA reported finding a large bruise on the resident’s hip and stated she immediately notified an RN, but there was no documentation of a physical assessment, investigation, or notification of the provider or family regarding this new injury. Nursing notes documented confusion with hallucinations, pain to both lower extremities that improved with repositioning, and elevated blood pressure, leading to an ED visit where hospital documentation referenced a possible fall, but the facility did not obtain or scan the full hospital record into the EMR. Upon the resident’s return, there was no documented comprehensive assessment, no fall investigation, and no documented notification of the provider or management about a possible fall.

Further changes in function and symptoms were documented but not acted upon as a change in condition. The resident’s functional status declined from one-person assist to needing two-person assist with a sit-to-stand device due to new onset sciatic pain, and a provider note documented right-sided sciatica that was not improving, leading to an order for gabapentin. Despite this, there was no documentation of a comprehensive assessment related to the new pain, the need for mechanical lift assistance, or the large bruise later identified. On a subsequent day, a nurse and the family member observed a large bruise and hematoma on the resident’s lower back and right thigh, and the resident reported that she had fallen in the bathroom several days earlier. An incident report was then completed, and management and the physician were notified, but this occurred several days after the alleged fall. During this period, documentation showed a marked increase in urinary and new bowel incontinence, a decline in ADL independence, and a downward trend in hemoglobin levels, yet there was no documented recognition or reporting of these as significant changes in condition. When the resident was ultimately transferred to the hospital, imaging revealed multiple new and worsened fractures, including comminuted bilateral sacral fractures with anterior subluxation of S1 on S2, pelvic fractures, and a large right buttock hematoma. Hospital consultants documented that she had cauda equina on presentation with no rectal tone and overflow incontinence, and that the fractures appeared new and worse compared to prior imaging, while facility records lacked timely assessments, investigations, and notifications consistent with the facility’s fall management policy and nursing standards cited in the report.

The facility’s own fall management policy required licensed nurses to complete incident/accident reports, document in the medical record and 24-hour report, notify the attending physician and responsible party of falls, and communicate falls to the interdisciplinary team. Fundamentals of Nursing references cited in the report emphasized the need for comprehensive assessments, timely reporting of significant changes in condition, and accurate, complete documentation. In this case, the record showed no timely incident report or investigation on the date of the alleged fall, no documented assessments of the large bruise when first identified, no documented follow-up on the ED note referencing a possible fall, and no documented recognition or reporting of the resident’s new or worsening pain, functional decline, continence changes, and hemoglobin drop as changes in condition. The NHA confirmed that staff did not report the injury following facility policy, that management was not notified of the alleged fall and injury until several days later, and that staff should have identified and reported the injury during daily care based on its size and extent.