F0610

D

Failure to Thoroughly Investigate Resident Fall and Involve All Witnesses

Tyrone, Pennsylvania Survey Completed on 03-31-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct a thorough investigation of a resident fall to rule out abuse or neglect. Facility policy required the nurse supervisor/charge nurse and department director or supervisor to promptly initiate and document an investigation of any accident or incident, including circumstances, witness names and accounts, and other pertinent data, with review by the safety committee. Resident 4 had moderate cognitive impairment, used a wheelchair, and had diagnoses including difficulty walking and generalized muscle weakness. On March 21, 2026, nursing documentation indicated the resident sustained a fall in the hallway, reported hitting his head, complained of severe left shoulder pain, and had a hematoma to the back of the head; the family requested transfer to the emergency department for evaluation.

Multiple staff interviews revealed that dietary staff, not nursing staff, first encountered the resident on the floor and physically assisted him before a nurse assessed him, but this information was not fully captured in the facility’s investigation. Nurse Aide 1 and Nurse Aide 2 reported that kitchen/dietary staff had picked the resident up off the floor, and Nurse Aide 3 stated she was told by a kitchen staff member that a resident was on the floor; when she arrived, the resident was already in a rolling desk chair, and she later assisted in transferring him to his wheelchair and submitted a witness statement. Dietary Aide 5 and Dietary Aide 6 each confirmed that they found the resident on the floor, could not locate a nurse, and together lifted him from the floor to a desk chair, with both indicating they completed witness statements. Registered Nurse 4, who was on another floor at the time of the fall, later assessed the resident in his wheelchair, noted he was guarding his arm, crying out in pain, and had hit his head, and sent him to the emergency room.

Despite these accounts, the facility’s written investigation of the unwitnessed fall included only witness statements from Nurse Aide 2 and LPN 7 and did not contain statements from the dietary aides who actually assisted the resident from the floor. Nurse Aide 2’s statement described finding the resident already in a wheeled desk chair and transferring him to his wheelchair, while LPN 7’s statement focused on environmental conditions and resident behaviors around the time of the incident and acknowledged she was on break when the fall occurred, returning after RN 4 was already assessing the resident. An orthopedic consultation later documented that the resident had a left proximal humerus fracture after a fall on cement. The Director of Nursing confirmed she did not obtain witness statements from dietary staff because she did not believe they would have assisted the resident in that way and also acknowledged she did not investigate the lack of RN assessment prior to the resident being moved to a rolling desk chair, despite the administrator’s statement that all staff were trained to report resident changes in condition to a nurse.