The July incident at Saint Therese at Oxbow Lake illustrates a pattern federal inspectors found during their August investigation: residents repeatedly fell while staff failed to implement individualized safety measures despite knowing their specific risk factors.
Three residents reviewed by inspectors fell a total of five times within days of admission. Each had been identified as high fall risk upon arrival, yet their care plans remained generic and unchanged even after accidents occurred.
The woman who fell trying to reach the bathroom had been admitted with a fractured left femur, dementia that worsened at night, and a history of falls. Hospital records showed she needed two staff members for any movement and required constant verbal cues for safety. Her admission assessment noted severe cognitive impairments and inability to bear weight.
Staff found her on the floor at 2:50 a.m. on July 27, just one day after admission. Her wheelchair wasn't near the bed and her call light wasn't activated. She had last been toileted at 10:45 p.m. — more than four hours earlier.
The fall assessment asked whether the care plan was updated with new interventions. Staff checked "No."
A second resident fell twice in four days. The man had been admitted with a traumatic brain injury, fractured femur, multiple rib fractures, and shoulder injuries from a previous fall. Hospital records showed he was confused and had dementia.
On his first night, July 20, staff found him on the floor next to his bed at 10:40 p.m. He told them the next morning, "I rolled out of bed." His call light was within reach but he hadn't used it due to confusion.
Four days later, staff found him on his bathroom floor. He said he "was trying to go use the bathroom." An incident report noted staff would check on him every two to three hours, but failed to address his obvious need for more frequent toileting assistance.
The third resident, a woman with Parkinson's disease, fell on July 28 while "rearranging clothes in her closet." She had been admitted with a urinary tract infection, diabetes, irregular heartbeat, and a documented history of falls at home.
Her family member told inspectors they had developed "a routine at home to help mitigate her falls which occurred from the time she got up in the morning to the time she went to bed." Staff never consulted them about these proven strategies.
When inspectors arrived, they found her room lacked basic assistive devices like a reacher tool that could help her access items safely. A "Call Do Not Fall" sign appeared on her wall only after inspectors began interviewing residents — her husband said staff hung it around 12:30 p.m. that day.
The facility's fall risk assessments contained significant errors and omissions. One resident's assessment incorrectly stated she was "free of falls since admission" despite having fallen days earlier. Another assessment marked a resident as having "two or more falls with injury" when records showed only one fall with no injury.
Critical risk factors went unrecorded. Assessments failed to note medications known to increase fall risk, failed to document conditions like atrial fibrillation and Parkinson's disease, and lacked comprehensive analysis of what caused each fall.
Nursing assistants told inspectors they relied on brief "Care Guides" that simply noted "fall risk" without specific interventions. One assistant said there "could perhaps be more information on the Kardex to assist with fall risk interventions, especially as the Care Guides just indicated fall risk and not much else."
Multiple nurses acknowledged they didn't update care plans after falls, saying that was management's responsibility. The nurse manager admitted staff "typically waited for her" to implement interventions, "especially if a fall occurred during the night hours."
The facility's medical provider told inspectors individualized fall interventions "should be implemented upon admission, if considered a fall risk, and then right after the first fall these should be reviewed and adjusted." After reviewing the three residents' care, he said he "would have thought staff would have initiated more specific interventions, adding, 'That is someone's job to put those precautions in place.'"
The director of nursing acknowledged that nurses were supposed to edit baseline care plans during admission assessments to provide individualized care "from the moment they arrive." She called this editing process "a work in progress."
One family member described the gap between institutional and family knowledge. His wife had fallen "many times prior to her admission," requiring constant vigilance at home. Staff never asked about the successful prevention strategies they had developed through hard experience.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Saint Therese At Oxbow Lake from 2024-08-07 including all violations, facility responses, and corrective action plans.