F0684

G

Failure to Assess, Notify, and Respond Appropriately After Unwitnessed Fall With Major Injury

Westminster, Colorado Survey Completed on 03-19-2026

Penalty

Fine: $17,215

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards following an unwitnessed fall. A cognitively intact resident with a history of falls, prior fractures (including a right humerus fracture), osteoarthritis, muscle weakness, and difficulty walking was admitted with orders and care plan interventions that included keeping the bed in the lowest position, use of a high-impact fall mat, and a lipped mattress. The resident required maximal assistance with transfers and used a wheelchair. On the night of the incident, the resident was found on the floor on her left side in a somewhat fetal position, partially on and partially off the fall mat, with the bed raised in a high position.

RN #1, who heard a loud sound and discovered the resident on the floor, documented an initial assessment that included vital signs showing elevated blood pressure and initiation of neurological monitoring. However, there was no documentation that RN #1 completed a thorough head-to-toe assessment before the resident was moved back to bed, despite facility policy requiring a nurse evaluation to determine presence of injury prior to moving a resident who has fallen. The record lacked evidence of a full assessment of injuries at the time of the fall, even though the resident later was found to have multiple fractures and a scalp contusion. Staff interviews, including from the DON and other nurses, confirmed that standard practice and policy required a complete RN assessment before moving a resident after a fall.

Following the fall, RN #1 did not notify the physician, the resident’s representative, or hospice at the time of the incident, despite facility policy and staff statements that the physician and responsible party should be notified immediately after the assessment. The resident’s blood pressure continued to rise over several hours, and she complained of pain, yet the first notification was to hospice at 6:00 a.m., approximately three hours after the fall. The hospice RN arrived around 6:30 a.m., found the resident arousable to verbal stimuli with tense features, facial grimacing, and reporting severe pain, and then notified the on-call physician, who ordered transfer to the hospital. Hospital imaging revealed a left parietotemporal scalp contusion, an acute nondisplaced C7 vertebral fracture, multiple displaced fractures of at least the first six left ribs, a left scapula fracture, and a left clavicle fracture. The facility also failed to ensure the resident’s bed was maintained at a safe, low height as care-planned, and the transfer to the hospital did not occur until after hospice assessment and physician notification several hours post-fall.

The resident’s representative reported that the resident lay in bed for three hours in severe pain without medical attention and that the family and physician were not notified by facility staff, but rather by hospice. Documentation showed that the facility did not contact the resident’s representative until later that afternoon, after the hospital had already identified multiple fractures and the resident was being admitted to intensive or trauma care. Staff interviews, including from CNAs, an LPN, an RN, and the DON, consistently described that facility practice required immediate RN assessment before moving a resident, prompt vital signs and neurological checks, and immediate notification of the physician and responsible party after a fall, particularly if there was pain or potential major injury. In this case, the facility failed to accurately and timely assess the resident after the fall, failed to promptly notify the physician and responsible party, did not ensure the bed was at the lowest and safest height, and did not ensure timely transfer to the hospital after an unwitnessed fall that resulted in major injury and pain.

The facility’s own fall care plan and incident policy emphasized prevention of avoidable accidents, completion of a nurse evaluation prior to moving a resident who has fallen, and documentation of injury status and notifications. Despite these requirements, the EMR lacked a full head-to-toe assessment at the time of the fall, and the DON acknowledged that RN #1, an agency nurse, failed to document the fall appropriately, complete an accurate assessment, and notify the physician and the resident’s representative. The hospice RN confirmed that RN #1 did not notify the physician or the resident’s representative and that hospice was contacted due to the resident’s increased pain and rising blood pressure. These actions and omissions collectively led to the cited deficiency for failure to provide treatment and care in accordance with professional standards and the resident’s care plan following the fall.