CNA D discovered the resident but did not complete the required physical assessment by a licensed nurse or notify the attending physician and resident representative as mandated by facility policy, according to federal inspection records from November 2025.
The violation occurred after extensive staff training on fall management. Records show CNA D attended fall management training sessions on August 10, 2025, and again on October 31, 2025. Both sessions were titled "Falls and Fall Management System" and conducted for all staff.
Following the training sessions, the Director of Nursing followed up with staff weekly for two weeks specifically about reporting requirements and following policy and procedures for falls and reporting.
The facility's Fall Management System policy, revised in December 2023, establishes clear requirements when residents sustain falls. The policy states it is facility protocol "to provide an environment that remains as free of accident hazards as possible" and "to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs."
The policy's procedure section specifically requires that "when a resident sustains a fall, a physical assessment will be completed by a licensed nurse" and "the attending physician and Resident Representative shall be notified of the fall and the resident status."
CNA D received no disciplinary action in their employee file until October 31, 2025, when they received their first write-up specifically concerning the incident where the "resident was on the floor and did not follow the facility policy and procedure."
The timing of the write-up coincided with the second fall management training session CNA D attended that same day, suggesting the facility addressed the policy violation through both disciplinary action and additional training.
Federal inspectors found the violation represented minimal harm or potential for actual harm and affected few residents. The finding falls under federal regulation F 0684, which addresses accident prevention and falls management in nursing facilities.
The inspection was conducted as a complaint investigation, indicating someone reported concerns about fall management practices at the facility to state health officials.
Record reviews showed the facility had established comprehensive fall management protocols and provided regular staff training on proper procedures. The violation occurred despite these preventive measures and the specific training CNA D had received just months before the incident.
The facility's policy emphasizes both prevention and proper response when falls occur. Beyond requiring immediate licensed nurse assessment, the policy mandates prompt communication with medical providers and family members to ensure appropriate medical evaluation and treatment.
Falls represent a significant safety concern in nursing facilities, particularly for elderly residents who may suffer serious injuries from falls that might cause minimal harm to younger individuals. Proper assessment by licensed nursing staff helps identify potential injuries that may not be immediately apparent.
The notification requirements serve multiple purposes: ensuring physicians can evaluate whether medical intervention is needed, keeping family members informed about their loved one's condition, and creating proper documentation of the incident for ongoing care planning.
CNA D's failure to follow these established procedures left gaps in the resident's care and communication chain. Without the required licensed nurse assessment, potential injuries could have gone undetected. The lack of physician and family notification meant key decision-makers remained unaware of the fall and the resident's status.
The facility's response included both corrective action against the individual staff member and system-wide reinforcement of fall management protocols through additional training. The Director of Nursing's weekly follow-up sessions demonstrated administrative awareness of the importance of proper fall reporting and management.
Federal inspectors documented the violation occurred despite the facility having appropriate policies in place and providing regular staff education on fall management procedures. The case illustrates the ongoing challenge nursing facilities face in ensuring all staff consistently follow established safety protocols, even after receiving specific training on those procedures.
The October 31, 2025 write-up in CNA D's personnel file marked the first documented disciplinary action against the employee, suggesting this was an isolated incident rather than part of a pattern of policy violations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carrollton Health and Rehabilitation Center from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
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