F0600

G

Failure to Report and Assess Resident-Reported Fall From Toilet Resulting in Hip Fracture

Willmar, Minnesota Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from neglect when staff did not follow required fall reporting and assessment procedures after the resident fell from a toilet. The resident had multiple diagnoses including stroke, ESRD, diabetes, CVA with left-sided hemiplegia/hemiparesis, was legally blind, required assistance of two staff for transfers and toileting per the care plan, and used a wheelchair or walker for mobility. The admission MDS indicated the resident was cognitively intact, frequently incontinent, dependent for transfers, and had a prior fall history. The care plan and Kardex specified assistance of two staff for ambulation, transfers, and toileting due to left-sided weakness and fall risk.

On the day of the incident, an activity assistant/nursing assistant (AA-A) reported that the resident requested to use the bathroom. AA-A stated she asked staff what level of assistance the resident required and was told he was assist of one with a transfer belt to the toilet. AA-A transferred the resident from bed to the toilet with assist of one, left him on the toilet with his call light, and reported she was told that other staff would transfer him off the toilet and back to bed while she went on break. Later, the resident reported that while sitting on the toilet he attempted to wipe himself, slid or tipped off the toilet, and fell forward onto the floor, landing on his left side. The resident, who was blind, stated that two female staff came into the room, lifted him under his arms from the floor, and put him back into bed, but he could not identify who they were.

Following the fall, the resident complained of left leg and knee pain, including during a physical therapy session where the PTA documented that the resident reported a fall from the toilet while staff reported no fall had occurred. The PTA noted left lower extremity knee, hip, and intertrochanteric band area pain with all movement and that attempts at transfer training were unsuccessful due to pain, and nursing was informed of these findings. Later that day, the resident continued to complain of worsening left leg pain, and during an evening nursing assessment he yelled out in pain with repositioning, with swelling noted to the left hip area. The resident again reported he had fallen off the toilet earlier. Nursing review of the earlier shift report showed that the resident had reported tipping off the toilet, but staff stated they had not witnessed a fall. The facility’s own fall communication policy required that all fall events, including resident-reported or suspected falls, be reported immediately to a nurse for prompt assessment, and that staff must never fail to notify the nurse if they are aware a fall occurred. Despite the resident’s report of a fall and subsequent pain, the fall was not promptly reported or assessed at the time it occurred, and the resident was moved from the floor back to bed without a nursing assessment, leading to delayed identification of a left hip fracture that required emergency evaluation and surgical repair.

Interviews with multiple nursing assistants revealed inconsistent accounts and denials of witnessing or assisting with the fall, even though the resident and his family member consistently reported that he fell from the toilet and was assisted from the floor by two staff. One NA reported receiving a social media message instructing her to "stick to the story" about the fall and that another NA had put the resident back into bed, though the message disappeared and could not be produced. Another NA acknowledged getting the resident up earlier in the day and later sending a message asking if anyone had called about the fall, but denied assisting him from the floor. The LPN on duty stated that when she was informed the resident wanted Tylenol and went to his room, the resident told her he had fallen from the toilet, but after interviewing the NAs, none admitted seeing a fall, and the nurse thought the resident was confused and simply passed the information to the next shift at the end of her shift. The facility’s investigation concluded that the resident had been transferred to the toilet by one employee despite a care plan requiring assistance of two, that the resident fell from the toilet, and that he was moved back into bed without assessment, constituting neglect as defined by regulation.