F0600

J

Failure to Ensure Safe Transfer and Timely Post-Fall Assessment After Head Injury

Picayune, Mississippi Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from neglect by not ensuring safe transfers, timely post-fall assessment, neurological monitoring, and prompt physician notification after a fall with a head injury. The resident had Alzheimer’s disease and a severely impaired cognitive status, with a BIMS score of 3, and physician orders for a Hoyer lift with two staff for transfers. She was also receiving aspirin and Plavix, both antiplatelet medications. On the night in question, while a CNA was providing incontinent care and repositioning the resident onto her side, the resident grabbed the bed or sheet and pulled herself toward the edge, slipping between the bed and the wall and falling to the floor on her right side.

Following the fall, the CNAs manually lifted the resident back into bed by her arms and legs without using the ordered mechanical lift and without a licensed nurse present to assess her at the time of the incident. Although CNA staff reported that they notified certain LPNs, those LPNs later denied being informed at the time of the fall. The facility’s incident report and late nursing documentation did not accurately capture the actual date and time of the fall, instead reflecting later dates and omitting the true timing of the event. The incident report also documented that the resident was assessed only after bruising was noted on the right shoulder, and it did not specify when the fall actually occurred.

Over the next one to two days, staff identified bruising and a hematoma on the resident’s head and right shoulder, with tenderness and guarded but functional range of motion. Neurological checks were not initiated immediately after the fall, and when a hematoma on the resident’s head was observed by an LPN, the medical provider was not notified at that time because the nurse believed the injury appeared old. The DON was not informed of the fall until two days after it occurred and did not review the earlier nursing notes documenting the hematoma, nor did he physically assess the resident’s head when he did assess her. The medical provider was not informed of the head hematoma and was only notified of the fall days later, at which point he ordered a right shoulder X-ray but no immediate evaluation for the head injury. The resident continued to receive aspirin and Plavix from the time the head injury was first documented until she was later transferred to the hospital for altered mental status, where imaging revealed a large right hemispheric subdural hematoma with midline shift. The facility’s failures in safe transfer technique, immediate licensed nurse assessment, timely neurological monitoring, and prompt physician notification after the fall and head injury were determined to constitute neglect and resulted in serious harm to the resident.

Removal Plan

• The Director of Nursing was notified by a Licensed Practical Nurse regarding discoloration observed on Resident #1's right shoulder.
• A Registered Nurse assessed Resident #1 and obtained an order for a right shoulder X-ray.
• The Director of Nursing contacted a Licensed Practical Nurse to inquire about any knowledge regarding Resident #1's fall.
• The Director of Nursing interviewed a Certified Nurse Assistant regarding Resident #1's fall and obtained a verbal account of the incident.
• The Director of Nursing interviewed a Licensed Practical Nurse regarding Resident #1's fall and obtained a verbal account of the incident.
• A Licensed Practical Nurse initiated a facility-based incident report regarding Resident #1's fall and completed the associated documentation of the event.
• The Director of Nursing reviewed Resident #1's neuro check log to ensure no abnormalities and continued neuro checks to monitor for neurological deficits.
• Nursing staff completed neuro checks for Resident #1 and found no neurological deficits, with the resident remaining at baseline.
• Resident #1 was noted to have drooping to the left side and slurred speech; the Nurse Practitioner was notified and orders were obtained to transfer to the local hospital.
• Resident #1 was transferred to the local hospital.
• The Director of Nursing conducted an audit of all current residents who had an accident or incident in the past thirty days to determine whether any other residents were potentially affected.
• The Director of Nursing provided education to all licensed nurses and Certified Nursing Assistants on fall prevention, safe handling, and proper resident transfers, including neuro checks, change in condition notifications, Abuse and Neglect protocols, Resident Rights, and the Vulnerable Adult Act, with staff required to complete the training before returning to work.
• The Medical Director, Administrator, Director of Nursing, Infection Preventionist, Assistant Director of Nursing, and Corporate Clinical Specialist held an ad hoc QAPI meeting regarding Resident #1's fall, the investigation, the immediate jeopardy, and the corrective action plan; the fall prevention policy was evaluated and reviewed to incorporate updated procedures and training for new staff on adhering to the Interact Care Path for acute mental status changes.
• A Resident Council meeting was held to inform residents that the facility received an Immediate Jeopardy citation due to inadequate lifting techniques and failure to assess a resident after a fall.
• The Administrator, Director of Nursing, and Corporate Clinical Specialist conducted a comprehensive review of the investigation to perform a root cause analysis and identified a failure in communication as the primary issue.
• A Certified Nurse Assistant received individual training on identifying each resident's lifting status per the care plan and safe handling/lifting procedures and received a disciplinary action.
• A Licensed Practical Nurse received a one-to-one inservice on Abuse and Neglect, Resident Rights, the Vulnerable Adults Act, notification of change in condition, fall prevention, and safe patient handling/moving protocols and received a disciplinary action.
• A Certified Nursing Assistant received individual training on identifying each resident's lifting status per the care plan and safe handling/lifting procedures and received a disciplinary action.
• The Director of Nursing conducted a training session for all licensed nursing staff regarding adherence to the Interact Care Path for acute mental status changes following post-fall assessments, with completion mandatory prior to return to work.