F0600

G

Unreported Shower Fall and Delayed Assessment Resulting in Resident Injuries

Wyndmoor, Pennsylvania Survey Completed on 03-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident was free from neglect when staff did not follow fall prevention and post-fall assessment policies, and did not report a fall with injury. Facility policy required that when a resident is found on the ground or has fallen, an RN must perform a complete head-to-toe assessment before the resident is moved, and 911 must be called immediately if the resident is unconscious, has difficulty breathing, or a severe injury is suspected. The resident involved had extensive medical history including traumatic cerebral hemorrhage, altered mental status, cerebral infarction, osteoporosis, encephalopathy, mobility and gait abnormalities, dementia, restlessness and agitation, paranoid personality disorder, and muscle weakness. The resident’s MDS showed cognitive impairment with a BIMS score of 3 and a need for partial/moderate assistance with tub/shower transfers, and the care plan included 1:1 nursing supervision at all times related to falls and confusion, with a physician order for 1:1 monitoring every shift due to falls.

On the day of the incident, the resident was assigned a 1:1 nurse aide for continuous supervision. The aide later admitted that the resident slipped and fell while getting up from a shower chair in the shower room. After the fall, the aide helped dry the resident and took the resident to the dining room for dinner, stating that the resident did not appear to be in pain. The aide did not perform or obtain a head-to-toe assessment by an RN before moving the resident, did not notify licensed nursing staff of the fall, and did not report the incident to anyone at the time. In a written statement, the aide initially claimed not to have seen the fall and stated that she only saw swelling and bruising on the left side of the resident’s face after dinner, and that she did not look at the resident’s face earlier.

Later that evening, the nursing supervisor coming on for the 7 PM shift observed the resident sitting in the dining room with significant facial swelling, bruising, and bleeding, including a swollen left eye and blood from the mouth. When questioned, the 1:1 aide said she did not know what had happened, and the agency charge nurse responded that the supervisor should ask the aide and stated she had 30 residents to manage. The supervisor questioned why the nurse had not noticed the injuries when administering medications earlier. The supervisor then reassessed the resident, noted continued nose bleeding, and contacted the nurse practitioner, who directed that 911 be called and the resident be sent to the hospital. Imaging in the emergency room revealed a subdural hematoma, a left zygomatic fracture, a mandibular fracture, and two fractured right ribs. In a subsequent interview with the Nursing Home Administrator, the aide initially denied any incident until confronted with the resident’s report, via interpreter, that the resident had fallen because the floor was slippery; the aide then admitted the fall in the shower room and stated she had been afraid to report it. The facility’s investigation substantiated neglect based on the aide’s failure to report the fall and injuries, resulting in a delay in assessment and medical treatment.