TYNDALL, SD - Federal health inspectors documented serious deficiencies in resident safety protocols at Good Samaritan Society Tyndall during a January 24, 2025 inspection, finding that failures in falls prevention programs led to injuries for multiple residents and that infection control practices fell short of industry standards.
Falls Prevention Program Failures Lead to Resident Injuries
The nursing home failed to properly identify and implement interventions to prevent falls for residents with documented fall risks, resulting in injuries including head trauma, lacerations, and facial bruising. Inspectors identified systemic failures in how staff assessed fall risks and communicated safety measures.
One resident with moderate cognitive impairment fell just one day after admission to the facility for rehabilitation following previous fall-related fractures. The resident was discovered on the floor at the foot of her bed at 8:15 a.m. on December 28, 2024, suffering a 2-centimeter head laceration with moderate bleeding, as well as bruising across the bridge of her nose and left hand. The fall occurred despite the facility's knowledge that she required assistance for ambulation and transfers.
The inspection revealed multiple environmental and procedural failures that contributed to this incident. At the time of the fall, the resident's bed was positioned at a high level rather than the lowest position, her wheelchair was not within reach, and the call light cord was wrapped around a grab bar attached to the bed. According to facility records, staff had last assisted the resident to the toilet at 5:59 a.m., more than two hours before she was found injured.
The facility's fall scene investigation noted that the resident "may not have been able to reach" the call light and that inadequate lighting and her status as a new admission may have contributed to confusion. The resident was incontinent and investigators noted she "could've been trying to grab" a remote control found under her bed when the fall occurred.
Inadequate Implementation of Fall Prevention Measures
Despite the facility's policy requiring comprehensive fall risk assessment and intervention, inspectors found that preventive measures were not properly implemented. While staff claimed to have provided hourly safety checks and education about call light use, proper footwear, and not bending over, there was no documentation in the resident's medical record that hourly safety checks had actually occurred.
More concerning, the resident had been assessed as having moderate cognitive impairment and confusion at the time of admission, raising questions about the effectiveness of educational interventions alone for a cognitively impaired individual. The facility had installed a grab bar on the resident's bed without assessing whether she could safely use it—a significant oversight given her cognitive status and unfamiliarity with the new environment.
The resident's December 27, 2024 falls assessment tool indicated she was at medium risk for falls, yet no interventions were selected in the action plan section of the assessment. This represents a fundamental breakdown in the falls prevention process, as identifying risk factors without implementing corresponding preventive measures provides no actual protection.
Repeat Safety Failures with Lift Equipment
A second resident with multiple sclerosis, Alzheimer's disease, and dementia experienced a fall on January 17, 2025 that revealed dangerous gaps in staff training and care plan documentation. This resident had a well-documented history spanning nearly a year of attempting to unhook or actually unhooking the straps from the total body lift used to transfer her—a behavior that poses extreme fall risk.
Medical records contained at least eleven separate incidents between April and November 2024 documenting this resident's pattern of removing lift straps, including instances where staff noted "this could be a safety issue if behaviors continue" and documentation of "safety concerns" related to her impaired decision-making and delusions about her ability to walk independently.
Despite this extensive documentation of unsafe behavior, the resident's care plan did not specify whether staff were required to supervise her while she used the bathroom or remain with her while she was connected to the lift equipment. When the resident fell on January 17, she was found on the bathroom floor with the lift straps disconnected. She sustained a large hematoma on the right side of her forehead and experienced pain with movement.
Clinical staff told inspectors that certified nursing assistants were trained that residents could be left connected to lift equipment while using the toilet, with tension removed so they weren't suspended. However, staff were expected to somehow intuitively know which residents could safely be left alone and which required supervision—a system that relies on informal knowledge rather than documented care plans.
Medical Implications of Falls in Vulnerable Populations
Falls in nursing home residents with cognitive impairment and mobility limitations carry significant risks beyond immediate injuries. Head trauma in elderly individuals, particularly those on blood thinners, can lead to intracranial bleeding that may not be immediately apparent. The resident who fell on January 17 had taken antidepressant, antipsychotic, and blood thinner medications within eight hours of the fall, placing her at elevated risk for serious complications from head injury.
Residents with conditions like multiple sclerosis already experience compromised balance, muscle weakness, and coordination difficulties. When combined with dementia-related impaired judgment and the resident's false belief that she could walk independently, the risk multiplies considerably. Falls in this population frequently result in fractures, prolonged hospital stays, functional decline, and increased mortality risk.
For residents recovering from previous fall-related fractures, subsequent falls can be catastrophic. The body's healing process after orthopedic surgery creates additional vulnerability, and a second significant trauma during the recovery period can derail rehabilitation progress and lead to permanent loss of independence.
Breakdown in Communication Systems
Inspectors identified fundamental failures in how fall prevention information was communicated to direct care staff. While the facility's policy stated that fall risks and interventions should be communicated through care plans, Kardex summaries, daily huddle reports, and bulletin boards, staff interviews revealed this system was not functioning effectively.
The clinical care leader acknowledged that certified nursing assistants "don't really use the Kardex" despite it being the primary tool for communicating care plan information. Instead, staff relied heavily on verbal communication between shifts and informal knowledge about which residents could be left alone—an approach that creates dangerous gaps when new situations arise or when different staff members work with residents.
Industry standards for falls prevention require that individualized interventions be clearly documented and readily accessible to all staff providing direct care. The care plan serves as the legal and clinical roadmap for resident care, and failure to update it following significant events like falls or changes in cognitive status represents both a quality of care failure and a liability risk.
Infection Control Deficiencies Compound Safety Concerns
Beyond falls prevention failures, inspectors documented infection control practices that failed to meet basic standards. Shared resident lift equipment throughout the facility had accumulated buildup of unidentified brown, brownish-orange, and black substances in footwells, with anti-slip coverings that were torn, peeling, loose, and rolling upward to expose additional contamination underneath.
These conditions persisted throughout the survey period from January 21-24, 2025, indicating they were not isolated incidents but rather reflected ongoing maintenance failures. Equipment used to transfer vulnerable residents with compromised immune systems and healing wounds must be maintained in sanitary condition to prevent transmission of pathogens.
Staff interviewed by inspectors were unable to confirm whether lift equipment underwent deep cleaning or was on any regular deep-cleaning schedule, though they believed it was wiped down after each use. The manufacturer's cleaning guide specified that germicidal spray or sanitizing wipes should be used, applied to a cloth rather than sprayed directly on equipment—procedures that would not address the type of embedded contamination observed.
Medication Administration Hand Hygiene Lapses
Inspectors also observed a registered nurse failing to perform hand hygiene at multiple required points during medication administration, including before donning gloves, after removing gloves, and when moving between contaminated and clean tasks. The nurse also used scissors from his shirt pocket—without cleaning or sanitizing them—to open a packet of powdered nutrition supplement for oral administration.
These lapses violated the facility's own hand hygiene policy, which specified that healthcare workers must perform hand hygiene when entering patient rooms, before preparing or administering medications, before donning sterile gloves, after removing gloves, and when moving from contaminated body sites to clean sites during patient care.
Hand hygiene represents the single most effective measure for preventing healthcare-associated infections. Failures during medication administration are particularly concerning because they can introduce pathogens directly into residents' bodies through oral medications, eye drops, or injections.
Additional Issues Identified
The inspection also documented a near-miss medication error when a nurse prepared an insulin pen at the correct 40-unit dose, had it verified by a second nurse, but the dose dial was somehow changed to 32 units before administration. Only surveyor intervention prevented the resident from receiving an inadequate insulin dose that could have resulted in elevated blood glucose levels and potential complications from poorly controlled diabetes.
The facility's fall prevention and management policy outlined appropriate procedures including completing falls assessment tools, care planning appropriate interventions, and communicating fall risks through multiple channels. However, the inspection findings demonstrated that policy existence alone does not ensure implementation, particularly when staff training, documentation practices, and accountability systems are inadequate.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Good Samaritan Society Tyndall from 2025-01-24 including all violations, facility responses, and corrective action plans.
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