F0689

G

Failure to Adequately Assess and Manage High-Risk Resident After Unwitnessed Fall

Olympia, Washington Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a known high fall-risk resident was adequately assessed and provided with appropriate supervision and resident-specific fall prevention interventions following a fall. The resident had severe cognitive impairment, dementia, metabolic encephalopathy, was dependent for ADLs, and was on Eliquis, an anticoagulant. The care plan identified the resident as at risk for falls related to advanced dementia, with interventions including non-skid socks, bed in lowest position, and staff reminders to use the call light. A fall risk assessment documented the resident as high risk due to a history of falls, incontinence, and anticoagulant use.

On the date of the incident, nursing progress notes documented that the resident had an unwitnessed fall to the floor in the dining room, apparently after dropping a stuffed animal and reaching to retrieve it. It was unclear whether the resident hit their head, and staff were aware the resident was on Eliquis. After the fall, the resident reported or demonstrated pain in the left hip and thigh, with redness noted to the left hip in one note, and later documentation that no bruising or redness was seen. The resident, who had severe dementia and difficulty verbalizing pain, showed obvious pain through facial grimacing and yelping when attempts were made to place a Hoyer sling and when being rolled onto the left side. Despite these signs, the resident was transferred from the floor to a wheelchair and then to bed using a Hoyer lift, rather than being immobilized in place.

Progress notes and the MAR showed that Eliquis 5 mg was administered later that day and was not held after the fall. Pain documentation was inconsistent, with pain levels recorded as 0/10 throughout much of the day, no pain score documented when Tylenol 650 mg was given, and later administration of oxycodone 5 mg for pain rated 7/10. A stat x-ray was ordered, but the radiology report confirming a left hip fracture was not completed until that evening. The resident’s family member reported that the resident was in pain for an extended period, that staff did not suggest sending the resident to the hospital sooner, and that the ambulance crew stated staff did not know details about the fall. The DON later acknowledged there was a lack of documentation on the resident’s status after the fall and stated the resident should have gone to the hospital if there was concern about a head injury or increased pain, and could not confirm whether the resident’s injury had been immobilized.