The Director of Nursing confirmed to federal inspectors that staff had not been trained specifically on orthostatic hypotension fall prevention techniques. Orthostatic hypotension causes dangerous drops in blood pressure when residents stand up, leading to dizziness and falls.
The DON told inspectors that individualized fall prevention plans should have been implemented for residents based on their fall histories upon admission. Floor nurses were supposed to provide step-by-step instructions to residents and certified nursing assistants for safe transfers and walking.
But no formal training program existed.
Instead, the facility operated under a blanket assumption that all residents were at risk for falls. Staff were expected to know general fall prevention measures without specific instruction on managing orthostatic hypotension episodes.
The DON acknowledged this gap during the December inspection. While individualized plans were supposed to guide care for residents with fall histories, the nursing assistants responsible for daily transfers and mobility assistance had never received targeted training on the condition that causes many preventable falls.
Federal inspectors cited the facility for failing to ensure adequate fall prevention measures. The violation affected few residents but represented minimal harm or potential for actual harm.
Orthostatic hypotension requires specific techniques during transfers and position changes. Without proper training, staff cannot recognize warning signs or implement protective measures when residents experience sudden blood pressure drops.
The facility's approach left nursing assistants to rely on general awareness rather than evidence-based techniques for preventing orthostatic hypotension falls.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookdale Greenwood Village from 2025-12-01 including all violations, facility responses, and corrective action plans.