F0580

G

Failure to Report Shower Fall and Timely Notify Physician After Resident Injury

Wyndmoor, Pennsylvania Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely notification to the physician of a fall incident and resulting injuries sustained by Resident R1, as required by the facility’s “Change of Condition” and “Falls Prevention and Management” policies. These policies direct CNAs to immediately notify a nurse of any change in a resident’s condition and require prompt notification of the resident, attending physician, and resident representative for significant changes, accidents/incidents, or transfers. The falls policy also requires a complete head-to-toe assessment after any fall, that the resident not be moved until assessed by an RN unless there is a life-threatening situation, and that 911 be called immediately if the resident is unconscious, has difficulty breathing, or a severe injury is suspected.

Resident R1 had a significant medical history including traumatic hemorrhage of the cerebrum, altered mental status, prior cerebral infarction, osteoporosis, muscle wasting, encephalopathy, mobility and gait abnormalities, dementia, restlessness and agitation, paranoid personality disorder, and muscle weakness. The resident had an active physician order for 1:1 monitoring due to falls and required partial/moderate assistance for tub/shower transfers, with a BIMS score of 3 indicating severe cognitive impairment. The care plan included a fall-related problem with interventions such as 1:1 nursing supervision at all times and environmental and cueing strategies to encourage use of the call bell and anticipate needs.

On the evening in question, CNA Employee E1, assigned to provide continuous 1:1 supervision, took the resident to the shower room and, by her later admission, the resident slipped and fell while getting up from the shower chair, landing on the left side. Employee E1 stated she did not see any injury, dried the resident, and took the resident to the dining room without reporting the fall to licensed nursing staff. Earlier, in her initial written statement, Employee E1 claimed she did not see the resident fall and only noticed swelling and bruising on the left side of the face after dinner but did not look closely at the face. She later admitted during an interview with the Nursing Home Administrator that the resident had fallen in the shower room and that she did not report the incident because she was afraid she would get into trouble.

Subsequently, another CNA, Employee E3, observed the resident with a nosebleed in the dining area at approximately 6:00 p.m. and brought the resident to the nurses’ station, informing the licensed nurse and CNA of the nosebleed. The agency nurse, Employee E2, who had oversight of the memory care unit, later reported she was not aware of the resident’s facial swelling, bruising, or bleeding until about 7:30 p.m., when the nursing supervisor, Employee E4, notified her. When Employee E4 arrived for the 7:00 p.m. shift and conducted rounds around 7:15 p.m., she observed the resident in the dining room with significant facial swelling, bruising, and bleeding, including a swollen left eye and blood from the mouth. Employee E4 questioned Employee E1, who said she did not know what had happened, and questioned Employee E2 about why the injuries had not been noticed earlier, leading to an argument about responsibility for assessing residents and reporting possible abuse or injuries.

Nursing notes later documented that at 9:18 p.m. the resident was observed lying on a couch as EMTs arrived, with swelling and bruising over the left mandibular area that felt tender, and that the resident was unable to explain what had happened. At 9:42 p.m., nursing documentation described left facial swelling and bruising and a nosebleed from the left nostril, with pressure applied to stop the bleeding and an order obtained to send the resident to the emergency room. Facility documentation submitted to the State Survey Agency and the facility’s investigation report confirmed that the resident was ultimately transferred to the hospital, where imaging revealed a subdural hematoma, a left zygomatic fracture, and acute right 3rd–4th rib fractures. Interviews with the DON and Nursing Home Administrator confirmed that CNA Employee E1 failed to notify licensed nursing staff of the fall and injuries, resulting in a delay in treatment after the fall in the shower room.