F0684

G

Delayed Response to Falls and Hypoxia Resulting in Resident Harm

Logan, Utah Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely assessment and treatment in response to changes in condition after falls and episodes of hypoxia, resulting in harm to residents. One resident with paroxysmal atrial fibrillation, difficulty walking, muscle weakness, and on anticoagulant therapy with an elevated INR experienced an unwitnessed fall in the bathroom. She was found on the floor in soiled clothing, assisted back to the toilet, and then to a chair. Initial neuro checks and vital signs were documented as baseline, and she denied hitting her head with no signs of injury noted. Later neuro documentation showed elevated blood pressure and lethargy, with slow response to verbal stimuli, weakness in hand grasps, and slurred speech, but there was no documented immediate escalation of care at that time.

Subsequently, the resident began complaining of a headache and then reported that she had hit her head at the time of the fall. Nursing notes documented nausea, vomiting, not following simple cues, and left-sided weakness in grip strength. Staff interviews indicated that a CNA reported the headache to the nurse, who administered medications including Tylenol and performed neuro checks, noting rising blood pressure but otherwise within normal limits at that time. When the resident vomited and her level of consciousness changed, with inability to open her eyes and no grip in the left hand, the nurse notified the wing nurse, who then initiated notifications and arranged for transfer. The resident was ultimately sent to the emergency department approximately 2.5 hours after the onset of significant change in condition, where a CT scan revealed a very large right subdural hematoma with midline shift and herniation. The facility later provided additional information but did not explain the 2.5-hour delay in sending her to the hospital after the change in condition, and the resident subsequently died.

Another resident with Parkinsonism, muscle weakness, difficulty walking, and sepsis sustained an unwitnessed fall and was found lying on the floor next to the bed, complaining of left hip pain. The nurse documented no new bruising or redness at the time, initiated neuro and vital sign checks, administered pain medication, and notified management, the physician, and family. An order was placed for a left hip x-ray, and the resident continued to receive oxycodone for left hip pain, with one dose documented as ineffective. The resident was not discharged to the hospital until later that afternoon, when an x-ray confirmed a left femoral neck fracture, resulting in a delay of approximately 10 hours from the time of the fall and initial complaint of hip pain to hospital transfer. In a later interview, the LPN stated he did not know why the resident was not sent to the emergency room sooner and believed it was probably because he did not have a physician’s order, and that he had attempted to manage the pain at the facility.

A third resident with muscular dystrophy, obstructive sleep apnea, and dysphagia experienced repeated episodes of low oxygen saturation without timely or consistent intervention. The resident had orders for cough assist every shift for airway management and BIPAP at night, though the BIPAP order was held for a period without documentation explaining why. Oxygen saturation readings showed multiple episodes of hypoxia, including values in the 80s, 70s, 60s, 50s, and as low as the 40s and 30s, often without documented follow-up saturations or immediate treatment. On one occasion, the resident’s sats were 80% and the provider ordered a chest x-ray and labs, but there was no documentation of treatment for low sats for four hours. On several other dates, low sats were recorded with no follow-up readings documented.

Staff interviews revealed that CNAs routinely checked sats early in the morning and that this resident’s sats were often in the 70s and 80s at night. A CNA described a night when the resident was hot and cold, calling frequently, and reported difficulty breathing; the CNA found his sats in the 40s and observed him to be blue in the face and pale. She finished assisting him with a urinal and taking out the garbage before informing the nurse, after which oxygen was started and his sats increased above 90%. Another nurse stated that it was not standard to check sats on night shift, but that if sats were low, oxygen should be provided and saturations rechecked, and that sats below 80% should be reported to the DON, physician, and family. The DON reported receiving a call that this resident’s nurse did not act fast enough when the resident had oxygen issues, and administration initiated an investigation, but the administrator stated she did not review the resident’s prior oxygen levels. These events demonstrate repeated failures to promptly assess and treat significant changes in condition, including post-fall injuries and severe hypoxia, in accordance with professional standards, care plans, and resident needs.