The August 26, 2024 fall happened when the resident returned from the bathroom and attempted to move from his wheelchair to bed. He told staff he got dizzy during the transfer and fell to the floor, landing on his left side. Another resident alerted nursing staff, who found him lying on the floor and helped him up using a gait belt.
Eight months later, federal inspectors discovered the facility had failed to follow its own fall prevention protocol. The resident's care plan, originally created in April 2017, contained no interventions related to the August fall that resulted in a head injury.
The facility's QA & A Falls Protocol, established in January 2015, required staff to investigate all falls to identify possible causes and prevention strategies. The policy mandated that charge nurses immediately evaluate residents for injury, complete head-to-toe assessments with vital signs, perform neurological checks, and document everything in the clinical record.
Nurses were supposed to notify physicians and families, complete incident forms, and place them in the Director of Nursing's mailbox. The DON then had responsibility for conducting further investigation, reviewing data, and interviewing staff or others knowledgeable about the event.
None of this happened.
The Director of Nursing told inspectors on May 20, 2025 that she didn't work at the facility when the fall occurred. She acknowledged she couldn't find any intervention for the August incident in the resident's records. She said she expected an intervention to be put in place at the time of the fall.
The facility's own policy required the DON to review information to determine if major injury occurred and whether to file a self-report with state authorities. The care plan should have been reviewed and revised with recommended actions, then communicated to direct care staff.
The policy specifically stated that medical records must reflect the occurrence, findings, action taken, and outcome as appropriate. For a resident who experienced dizziness during transfer and struck his head, this documentation gap represented a significant safety failure.
Falls among nursing home residents often signal underlying medical conditions or environmental hazards that require immediate attention. Dizziness during transfers can indicate medication side effects, blood pressure problems, or other treatable conditions. Without proper investigation, the facility missed opportunities to prevent future falls.
The resident's care plan dated back to April 2017, nearly seven years before the fall. Federal inspectors found no evidence that staff had updated fall prevention strategies based on the August incident, despite the facility's written commitment to investigate all falls and implement preventive measures.
The violation occurred under federal tag F689, which requires nursing homes to ensure each resident receives adequate supervision and assistance to prevent falls. Inspectors classified the harm level as minimal, affecting few residents.
The inspection took place on May 21, 2025, nearly nine months after the original fall. By then, the resident had gone without updated fall prevention interventions for the entire period, despite having experienced dizziness and head trauma during his last documented fall.
Stratford Specialty Care's failure to follow its own fall protocol left a vulnerable resident without the safety measures the facility's policies promised to provide.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stratford Specialty Care from 2025-05-21 including all violations, facility responses, and corrective action plans.