Failure to Implement Fall Response Protocol After Resident Reported Fall and Pain
Penalty
Summary
The deficiency involves the facility’s failure to identify, assess, and investigate a potential fall after a high fall‑risk resident reported pain and stated she had fallen. The resident had multiple right‑sided rib fractures, pneumonia, dementia, moderate cognitive impairment, used a wheelchair and walker, and required supervision and moderate assistance with ADLs. A Morse Fall Risk assessment identified the resident as high risk for falls with a score of 80 and a history of falls and overestimation of functional abilities. On the morning in question, a CNA reported the resident pointed to her right lower back and hip indicating pain during morning care. An RN and LVN supervisor assessed the resident, who again indicated pain and told the LVN supervisor she had fallen. Despite this, the RN did not believe a fall occurred because there was no visible bruising, and the DON later confirmed that no fall incident report was completed because the fall was unwitnessed and the CNA had not observed it. The facility’s own investigation summary documented that the resident had reported to multiple staff, including a CNA and therapy staff, that she had experienced a fall, and later that evening the resident reported pain while being assisted to the bathroom with a front‑wheel walker. A CT scan performed subsequently showed probable acute, nondisplaced fractures of the right 5th and 10th ribs, and progress notes documented that the resident stated she had fallen when asked about her pain. The DON acknowledged that staff did not implement the facility’s fall policies, which defined a fall as one that may be witnessed or reported by the resident or any observer and required post‑fall assessments, neurological monitoring for unwitnessed falls, incident reporting, reassessment of mobility status, and IDT review. As a result, required post‑fall assessments, 72‑hour neurological checks, incident reporting, and interdisciplinary review were not initiated when the resident first reported a fall and pain.
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