F0689

D

Failure to Implement Post-Fall Interventions, Notify Families, and Follow Transfer Orders

Creve Coeur, Missouri Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its fall management and evaluation policies after multiple unwitnessed falls and an injury during a staff-assisted transfer. For four residents who experienced unwitnessed falls, staff did not identify or implement new interventions to reduce the likelihood of additional falls, and the interdisciplinary team (IDT) did not document post-fall assessments or care plan revisions as required. The facility’s policies required completion of an incident report and post-fall assessment within 24 hours, root cause analysis, IDT review within 72 hours, and documentation of new interventions and care plan updates, but these steps were not carried out or documented for these residents.

One cognitively intact resident with diagnoses including hypertension, anxiety, restless leg syndrome, and spinal pain had an unwitnessed fall from bed, resulting in a skin tear to the left elbow, bruising on the left scapula, and reported pain rated seven out of ten. The incident report showed the DON and physician were notified, but the resident’s family/responsible party was not notified, and there were no IDT notes or new interventions added to the care plan following the fall. Another resident with moderate cognitive impairment, dementia, Parkinson’s disease, stroke, seizures, and a history of repeated falls slid from a wheelchair to the floor in the hallway, sustaining a facial abrasion. The incident report documented notification of the DON and physician, but not the family/responsible party, and there were no IDT notes or additional interventions documented after this fall.

A resident with severe cognitive impairment and multiple diagnoses including dementia, hypertension, stroke, diabetes, and anxiety had a fall with injury, with staff finding the resident on the floor with a swollen left wrist and complaints of hip pain, leading to transfer to the hospital. Although the incident report indicated the physician, DON, and a family member (by message) were notified, there was no post-fall risk evaluation, IDT documentation, or new interventions added to the care plan. Another resident with severe cognitive impairment, seizures, dementia, hypertension, sleep disorder, osteoarthritis, and a recent history of falls had an unwitnessed fall while trying to get into bed. The incident report noted no injuries and stated that family and physician were aware with no new orders, but listed no people notified, and there were no IDT notes or new interventions documented following this fall.

The facility also failed to ensure that staff followed physician orders and the care plan for a resident requiring a full-body lift transfer with three staff. This resident, cognitively intact with diagnoses including heart failure, morbid obesity, anxiety, chronic pain syndrome, hypertension, muscle weakness, and right knee pain, had an order and care plan specifying transfer with a full-body lift and three people. The resident later reported that two agency CNAs transferred them with a Hoyer lift, turned them without informing them, and during lowering into the chair, the crossbar scraped their hand and wrist, causing a skin tear and bruising. There was no incident report, no skin assessment on the date of the incident, no documented notifications to the physician or responsible party, and no post-incident monitoring notes for 72 hours. Subsequent observation showed two CNAs performing the Hoyer transfer without a third staff member, and both CNAs stated they were unaware of the three-person transfer requirement in the care plan, indicating staff did not follow the ordered transfer protocol.