F0689

G

Failure to Implement Fall-Prevention Interventions and Post-Fall Assessment

Wayne, New Jersey Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s failure to implement adequate fall-prevention interventions and to thoroughly assess and monitor a resident after a fall and subsequent signs of injury. The resident was admitted with multiple significant diagnoses, including acute respiratory failure, muscle weakness, schizoaffective disorder, seizures, and functional quadriplegia, and had a BIMS score of 9/15, indicating moderate cognitive impairment. A comprehensive nursing assessment documented that the resident’s mobility was very limited, that they were unable to make frequent or significant changes independently, and that they were dependent on others for ADLs. Progress notes prior to the incident documented that the resident required total care with two-person assist for repositioning, but the baseline care plan, while identifying a fall risk focus area, did not specify the resident’s fall risk level or the number of staff required to assist with repositioning in bed.

On the date of the fall, the Facility Reportable Event (FRE) stated that while a CNA was providing care, the resident was squirming and holding the side rail while being turned in bed, and the resident’s lower legs fell off the bed while the torso remained on the bed. The CNA and an RN then repositioned the resident back to bed and assessed the resident. However, there was no documented evidence that the facility implemented any interventions following this fall to address the resident’s fall risk or to protect the resident from further injury. An employee statement from the CNA did not indicate that two staff assisted with repositioning during the care at the time of the incident, and in a subsequent interview, the RN confirmed that she did not assist the CNA with repositioning, only assessing the resident afterward and noting no pain. The RN did not provide information regarding follow-up interventions or the required level of care for the resident.

In the days following the fall, the facility failed to adequately assess and monitor the resident for pain and injury. The FRE documented that an LPN later noticed bruising on the resident’s bilateral lower extremities, and other staff statements described the resident exhibiting signs of pain, flinching during assessment, and having bruising on both thighs and the lower back. The resident was then sent to the hospital, where imaging revealed acute fractures of the distal shafts of both femurs and a suspicious subtle fracture at the base of the proximal phalanx of the right third finger, associated with pain and bruising. The facility’s FRE did not address the right-hand swelling and bruise, and there was no documentation regarding the origin of the right-hand injury. The facility’s investigational summary concluded that the bilateral femur fractures identified later were the result of the earlier fall, but there was no evidence that the facility monitored the resident for pain and injury after the fall or implemented interventions on the date of the fall to prevent further injury, despite a policy stating that appropriate and immediate interventions and root cause analysis would be conducted for incidents and accidents.