F0550

D

Failure to Follow Fall Protocols and Provide Timely Assessment After Assisted Fall

Houston, Texas Survey Completed on 03-09-2026

Penalty

Fine: $37,720

Summary

The deficiency involves the facility’s failure to treat a cognitively intact resident with respect and dignity and to follow fall protocols, including timely nursing assessment and reporting, after an assisted fall. The resident was an older female with a history of stroke resulting in hemiplegia/hemiparesis on the left side, muscle weakness, lack of coordination, morbid obesity, and other neurologic and functional impairments. Her discharge MDS showed a BIMS score of 13/15, indicating she was cognitively intact, and she required extensive assistance for bed mobility and transfers, with helpers doing all the effort or requiring two or more helpers. Her care plan identified her as at risk for falls related to weakness and hemiplegia/hemiparesis.

According to the complaint and interviews, the resident experienced an assisted fall during a wheelchair-to-bed transfer performed by two CNAs. One CNA reported that during the transfer the resident began to slip, her leg slipped forward, and she was slowly lowered to the floor. The resident stated she heard a crack, was lowered to the floor, cried while on the floor, and that the CNAs struggled to get her back into bed. She reported significant pain that night, difficulty sleeping, and emotional distress as she replayed the fall in her mind. Her roommate later observed her curled up in bed, crying and whimpering, and reported that the resident said she had a “nasty fall” and was in pain. The roommate stated the resident continued to whine and whimper in bed for hours.

The facility did not ensure that the fall was promptly assessed and reported according to protocol. The DON stated that all falls were to be reported to her, but she was not notified until days later, after the resident complained of leg pain. There were conflicting accounts among staff: the CNAs stated they reported the fall to an LVN, while the LVN initially stated she had not been made aware of the fall, then later stated she was contacted by the ADON about a reported fall and was instructed to perform a head-to-toe assessment, which she said the resident refused. The resident’s pain assessments on the MAR showed varying pain scores over the days following the fall, culminating in a severe pain score, and only then was she assessed by nursing leadership, found to have pain and swelling in the left leg, and sent to the hospital where a left femur fracture was diagnosed. The family was not informed of the fall until the day of transfer to the hospital. These actions and inactions demonstrate that the facility did not follow its fall protocols, did not ensure timely nursing assessment after the fall, and did not uphold the resident’s right to dignified care and communication about her condition.