The October 13 fall at Bremond Nursing and Rehabilitation Center involved a resident already identified as high-risk for falls due to unsteady gait, muscle weakness, and cognitive impairment. Her care plan specifically outlined interventions to prevent injuries, including non-skid footwear and keeping her bed in the lowest position.
The incident occurred at 7:30 PM and was classified as "unwitnessed" in facility logs. But during an October 15 interview, the director of nursing admitted she had actually seen the resident on the floor that evening. She told inspectors she treated it as an unwitnessed fall anyway and initiated the required incident report and assessments.
What she didn't do was write a progress note.
"She stated she did not document a progress note but should have," inspectors wrote.
The resident's medical record from October 13 through October 15 contained no mention of the fall. A fall risk evaluation completed at 11:28 PM on October 13 showed she scored 14 points, indicating she remained at risk for future falls.
When inspectors interviewed the resident on October 25, she was sitting in a wheelchair wearing clean clothes with no visible bruises or injuries. She said she felt good after a recent shower.
Asked about falls at the facility, she gave a startling response: "About 25 times."
She repeated the number when asked again. Despite claiming multiple falls, she denied pain or injuries and said she felt safe at the facility. "She wanted to stay there forever," inspectors noted.
The documentation failure violated multiple facility policies. The nursing home's incident and accident policy, reviewed in April, requires staff to "report, investigate, and review any accidents or incidents that occur or allegedly occur on facility property and may involve a resident."
Specifically, the policy states: "The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained for follow-up interventions."
The facility's fall prevention program policy, revised just one day after this resident's fall, outlines even more detailed requirements. When any resident experiences a fall, staff must assess the resident, complete a post-fall assessment, finish an incident report, notify the physician and family, review and update the care plan, document all assessments and actions, and obtain witness statements if injury occurs.
The director of nursing completed some of these steps. She initiated incident reports and assessments. But the progress note documentation that would have created a permanent medical record of the fall and her direct observation never happened.
This resident's case illustrates broader concerns about fall prevention and documentation at facilities caring for cognitively impaired elderly patients. Her care plan acknowledged multiple risk factors including history of falls, yet she reported experiencing approximately 25 falls during her stay.
The inspection report doesn't indicate how long she had been a resident or over what time period these alleged falls occurred. It also doesn't specify whether all 25 falls she claimed were properly documented, investigated, or led to care plan modifications.
Federal nursing home regulations require facilities to ensure each resident receives care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This includes implementing fall prevention programs and maintaining accurate medical records.
The documentation gap creates potential problems for continuity of care. Without progress notes describing what the director of nursing observed, future caregivers reviewing the medical record would have incomplete information about the resident's fall history and circumstances.
Progress notes serve as the primary communication tool between healthcare providers across shifts and disciplines. They document not just what happened, but also the clinical judgment and observations of the nurse who witnessed events firsthand.
In this case, the director of nursing possessed direct knowledge about how and where she found the resident, the resident's condition immediately after the fall, and any immediate interventions provided. None of that clinical information made it into the permanent medical record.
The resident appeared uninjured when inspectors observed her nearly two weeks later. She expressed satisfaction with her care and desire to remain at the facility. But the missing documentation represents a systemic breakdown in required safety protocols designed to protect vulnerable nursing home residents.
The facility's fall prevention policy was updated on October 14, the day after this incident occurred.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bremond Nursing and Rehabilitation Center from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Bremond Nursing and Rehabilitation Center
- Browse all TX nursing home inspections