F0610

D

Failure to Investigate and Document Resident Fall With Forehead Laceration

Las Vegas, New Mexico Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The facility failed to thoroughly investigate a fall with injury involving one resident. Progress notes documented that the resident experienced a fall resulting in a 7.0 cm by 2.0 cm laceration to the right side of the forehead and was transported to a local hospital. The resident’s daughter reported that she was first informed of the incident by the hospital, which called her for permission to treat the forehead laceration caused by the fall at the facility. The DON stated that no investigation had been conducted for this fall, she could not confirm the exact time of the incident, and she was unable to locate documentation of a change in condition related to the fall with injury. The DON also could not confirm who witnessed the fall or how it occurred and acknowledged that the incident should have been investigated and reported to the State Agency but was not.

Staff interviews further showed incomplete documentation and lack of investigative follow-up. The DON confirmed that the resident’s medical record was not complete and that notes were not thorough regarding what occurred during the incident. An LPN stated that she did not witness the fall but heard a loud noise and a CNA yelling that the resident was on the floor; she then observed the resident on the floor with a forehead laceration, arranged for transfer to the hospital, and wrote a progress note, but did not conduct an investigation. An RN reported that he also did not witness the fall, heard the CNA yell, found the resident on her side face down and bleeding, applied gauze, had the resident returned to her wheelchair and taken to her room, and that the oncoming nurse later sent the resident to the hospital. The RN acknowledged that he did not document the incident or his observations in the resident’s medical record.