F0684

D

Failure to Report and Assess Resident Fall Resulting in Undiagnosed Fractures

Asheville, North Carolina Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was properly assessed by a nurse after a fall because a nurse aide did not appropriately report the fall. The resident had dementia with severe cognitive impairment and a history of two or more prior falls without injury. On the evening in question, the resident was in or near her room handling tray lids when she lost her balance and fell. NA #2 witnessed the fall, helped the resident up, and assisted her back to bed instead of leaving her in place and immediately notifying a nurse for assessment. In her written statement, NA #2 said she told the nurse that the resident had fallen, but in a later interview she admitted she did not report the fall correctly and acknowledged she should have reported it.

Around the same time, Nurse #2 heard the resident scream and went to the room, finding the resident already in bed, tense and frightened but without obvious signs of pain, bruising, or swelling. Nurse #2 questioned NA #2 in the hallway; NA #2 appeared agitated and only described the resident taking tray lids off the cart, without mentioning a fall. NA #1, who was nearby, corroborated that he heard the scream, saw NA #2 coming out of the resident’s room, and heard NA #2 tell Nurse #2 only that the resident had been taking tray lids off the cart, with no report of a fall. As a result, Nurse #2 did not have information that a fall had occurred and did not perform a focused post-fall assessment at that time.

Later that evening, during the night shift, NA #3 attempted to get the resident up for a scheduled shower and found she could not stand, appeared weak, and struggled to get up. NA #3 reported this to Nurse #3, who then assessed the resident and noted that she could only take one or two steps before yelling out and grabbing her right leg, and that her right elbow was swollen. Nurse #3, who had not received any report of a new fall on that date and only knew of a prior fall two days earlier, contacted the on-call provider and obtained orders for x-rays of the right elbow, hip, and leg. The x-rays, completed the following day, showed acute fractures of the right olecranon and right hip/femoral neck, leading to the resident’s transfer to the hospital for surgical repair. The facility’s DON, Administrator, NP, and Medical Director all stated that NAs should not move a resident after a fall and should notify a nurse so the nurse can assess for injury, and that the facility’s fall protocol required a nurse assessment before moving a resident, which did not occur immediately after this resident’s fall because the fall was not properly reported by NA #2.