F0842

D

Failure to Document Complete Post-Fall Nursing Assessments

Bristol, Connecticut Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to complete and document nursing assessments in the medical records at the time of residents’ falls, as required by facility policy and professional standards. For Resident #1, who had Parkinson’s disease with dyskinesia, dysarthria, anarthria, generalized muscle weakness, lack of coordination, difficulty walking, anxiety disorder, impaired cognition, and a history of falls, the care plan identified multiple fall risks and required assistance with ADLs and toileting. After a fall on 2/7/26, RN #1 documented that the resident was found seated on the floor attempting to get up, with a facial laceration and bleeding, that EMS was notified, the resident remained on the floor until EMS arrival, and that the resident was transferred to the hospital. The note also documented notification of the on-call provider and the resident’s representative.

However, the clinical record for Resident #1 did not include documentation that range of motion (ROM) was assessed for additional injuries or pain following the fall, and there was no completed Situation, Background, Assessment, Recommendation (SBAR) form to show that a full assessment had been performed. In interview, RN #1 stated she had performed a full assessment, including ROM and neurological signs, but acknowledged she did not document her findings and that the assessment should have been documented before the end of her shift. This lack of documentation conflicted with the facility’s Falls Protocol policy, which directed nurses to assess and document vital signs, recent injury, musculoskeletal function including changes in ROM or weight bearing, cognition and neurological status, pain, and details of the fall.

For Resident #2, who had a scaphoid fracture of the left wrist, weakness, Alzheimer’s disease, aphasia following cerebral infarction, severe cognitive impairment, and required substantial assistance with mobility, the care plan identified fall risk related to new admission, cognitive impairment, and generalized weakness. After a fall on 2/10/26, RN #2 documented that the resident was found on the right side on the floor, with the right hip reddened from lying on it, and that the resident denied pain; vital signs were obtained and the provider was notified. The record did not show any new orders for monitoring the reddened hip, did not document that ROM was assessed for further injuries, and did not contain an SBAR documenting a full assessment. Later documentation by the DON noted that the resident was subsequently found with a bump on the right side of the head and inability to move the neck, and hospital records showed admission for an acute displaced type II odontoid fracture. In interview, RN #2 stated she had performed a full assessment including movement and ROM but did not document it, and the DON confirmed that both RNs should have documented full post-fall assessments in the nurse’s notes or SBARs in accordance with the facility’s Falls Protocol and Charting Documentation policies.