F0689

G

Failure to Document, Report, and Investigate Resident Fall With Possible Arm Injury

Higginsville, Missouri Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete and document an incident report, make required notifications, and investigate a fall with possible injury for one resident. The resident was a new admission on hospice with multiple diagnoses including kidney disease, depression, anxiety disorder, atrial fibrillation, hypertension, and a history of knee surgery. Assessments documented that the resident was disoriented to person, place, and time, chair bound, dependent on staff for all ADLs, unable to bear weight, and required a full body mechanical lift for transfers. The resident had a high fall risk score, a history of falls prior to admission, and was receiving multiple pain and psychotropic medications. Behavior notes showed that shortly after admission the resident was restless, repeatedly trying to get out of bed and out of a recliner, and required staff to sit in the room to maintain safety.

On the night in question, an agency LPN working night shift reported later (via follow-up contact) that the resident rolled out of a low bed onto a floor mat between midnight and 1:00 a.m. The resident was found lying partially on his/her back/side on the mat. The agency LPN stated that a head-to-toe assessment was completed, that no injuries or changes in range of motion were noted, and that the resident did not vocalize or show signs of pain. The LPN and an agency CNA attempted to use the full body mechanical lift but could not get it low enough, and instead physically lifted the resident back into bed. The LPN did not obtain or document vital signs after the fall, did not write a nursing note about the incident, did not complete an incident report, and did not notify the physician, hospice, responsible party, or facility leadership. The LPN acknowledged understanding that an incident report and notifications were required but stated that the unit was very busy and that these tasks were not completed during the shift.

The following day, nursing documentation showed that when a day-shift LPN went to assess the resident, the resident appeared lethargic with low oxygen saturations and was noted to have his/her right wrist and hand bent at the wall, grimacing with movement of the arm, and later observed with swelling and bruising of the right wrist and elbow and the arm in an awkward position. Hospice documentation on the same day described the resident as restless and moaning, with the right arm bent at a 90-degree angle, the wrist hanging off the side of the bed, swelling from elbow to fingertips, coolness to touch, and weak pulse, with an estimated pain score of 9 on a non-verbal pain scale. Hospice recorded that facility staff reported the resident had rolled out of bed early that morning and that hospice had not been notified at the time of the fall. Review of the medical record showed no nursing note on the day of the fall, no documentation of the fall event, no incident report, no recorded vital signs or neurological checks related to the fall, and no documented notifications to the physician, hospice, or responsible party. There was also no documented facility investigation or root cause analysis of the injury after the agency LPN later acknowledged that the resident had fallen from bed.

Additional interviews and a coroner’s report confirmed that the fall from bed onto the floor mat was not reported to facility administration, the physician, hospice, or the family at the time it occurred, and that there was no contemporaneous documentation in the resident’s record describing the circumstances of the fall or any immediate assessment. The family member stated that the facility never notified him/her of the fall or the apparent arm injury and that he/she learned of the suspected injury from hospice. Hospice staff stated that hospice should have been notified as soon as the resident fell and that they were not informed until the following day when the resident was already exhibiting increased pain and arm deformity. The facility’s fall policy described expectations for assessment and care planning but did not specify who must be notified or how falls should be documented, and the record review confirmed that required documentation and notifications related to this resident’s fall and possible injury were not completed.