The resident, identified as Resident 5 in the September inspection report, was observed on September 1 with a bandage on his right hand. When asked about it, he told staff he had fallen the previous night on August 31.
Despite this clear report of a fall with visible injury, the facility failed to follow any of the safety protocols outlined in their written policy for fall incidents.
The facility's policy on fall investigations requires extensive follow-up whenever a resident falls. Staff must complete a Risk Management Assessment to determine what caused the fall. An interdisciplinary team meeting must be held to identify factors that contributed to the incident. The care plan must be updated or created to address newly identified risk factors.
None of this happened for Resident 5.
The policy also requires nurses to document specific details about each fall: a description of what happened, medications involved, environmental conditions, equipment factors, and contributing medical issues. Staff must identify patterns like time of day and location. They're supposed to develop an action plan to prevent future falls based on what they learn.
Again, none of this occurred.
Medical records show the resident had cognitive capacity to report what happened to him. His most recent assessment gave him a BIMS score of 14, indicating he was "cognitively intact" and able to understand and communicate about his condition.
Yet when Resident 5 clearly told staff about his fall and showed up with a bandaged hand, the response was to do nothing.
The inspection revealed additional confusion about the resident's fall history. While nursing notes from September 1 document his report of falling on August 31, a separate medical summary from September 7 describes him having "a fall outside in front of the facility." It's unclear whether these refer to the same incident or represent multiple unreported falls.
When inspectors interviewed Resident 5 on September 10, he provided more details about his injuries. He said he fell "the night before he went to the acute care hospital" and sustained a scab on his left knee, which he showed to inspectors. This suggests he suffered injuries to both his hand and knee from the fall.
The registered nurse who was on duty when Resident 5 reported his fall admitted the facility's failures during an interview with inspectors. RN 1 confirmed that the resident had reported falling the night before on September 1. She acknowledged she never completed a "change of condition" assessment to monitor him after the fall report.
RN 1 also verified that no care plan was updated following the fall. No Fall Risk Assessment was completed. No interdisciplinary team meeting was held to discuss what happened or how to prevent future incidents.
These omissions directly contradicted the facility's written policy, which states that "significant information obtained as a result of the IDT should be reported to the physician and family and documented in the Medical Records."
The Director of Nursing confirmed these were serious policy violations when interviewed by inspectors. The DON said she expected licensed nurses to monitor residents who report falls, update care plans, complete Fall Risk Assessments, and hold IDT meetings "after each episode of a fall."
When informed of the inspection findings, the DON acknowledged the failures had occurred.
The facility's policy emphasizes that fall investigations serve a critical safety purpose. The document states it is facility policy "to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury."
By skipping the investigation entirely, staff missed the opportunity to identify why Resident 5 fell and what changes might prevent him from falling again.
The policy requires staff to look for patterns in falls - noting when they happen, where they occur, what activities preceded them, and whether other residents were involved. This systematic approach helps facilities spot environmental hazards, medication side effects, or care gaps that increase fall risk.
For Resident 5, none of this analysis took place. His reported fall became a missed opportunity to improve his safety and potentially prevent future injuries.
The inspection classified this as a violation with "minimal harm or potential for actual harm" affecting "few" residents. However, inspectors noted the failure "had the potential for the delay in providing the necessary care and services and posed a risk for Resident 5 to sustain serious injury."
Falls represent a leading cause of injury among nursing home residents. The facility's detailed written policy acknowledged this risk and outlined specific steps to address it. But when a resident actually reported falling and showed visible signs of injury, those protective measures were simply ignored.
Resident 5's bandaged hand served as physical evidence that the fall had occurred and caused harm. Yet even this clear indicator wasn't enough to trigger the safety protocols the facility had promised to follow.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for St. Catherine Healthcare from 2025-09-16 including all violations, facility responses, and corrective action plans.