Carlyle Senior Care of Fountain Inn admitted the 89-year-old resident in April with severe cognitive impairment and multiple fall risk factors. The resident scored just 3 out of 15 on a mental status test, indicating severe cognitive decline, and required assistance moving between bed and chair.
Staff developed a care plan on April 17 identifying the resident as high-risk for falls due to altered balance, mental status changes, blood pressure medications, heart disease, poor coordination, previous falls, unsteady walking, and vision problems.
On May 5, a nursing assistant found the resident on the floor underneath their bed after an unwitnessed fall. The resident showed no visible injuries or bruising from the incident.
Physical Therapist #9 completed a post-fall assessment the same day, documenting that the fall was discussed with the facility's care team. As a result, staff implemented hourly safety rounds starting May 6 — a intervention designed to check on high-risk residents every hour to prevent future falls.
The facility's own fall prevention policy required staff to identify causes within 24 hours of any fall and implement interventions to prevent subsequent incidents. The policy stated that staff must "continue to collect and evaluate information" until fall causes are identified or determined to be uncorrectable.
But the hourly rounds never happened.
During the December inspection, Director of Nursing could not locate any documentation showing that staff had conducted the promised hourly safety checks. The resident's medical record contained no evidence that anyone had followed the care plan intervention implemented after the fall.
The resident remained at the facility for more than six months after the fall incident, finally discharging in November. During that entire period, no records showed staff conducting the hourly rounds meant to prevent another dangerous fall.
When asked about the missing documentation, the facility's Administrator acknowledged that he would expect staff to follow residents' care plans. However, the inspection revealed a seven-month gap between the care plan requirement and any evidence of implementation.
The resident's case highlighted broader concerns about fall prevention at the facility. Federal data shows that nursing home residents with severe cognitive impairment face significantly higher fall risks, particularly when they have multiple contributing factors like heart conditions and balance problems.
The facility's policy acknowledged this reality, requiring comprehensive assessment and intervention for residents who fall. Yet despite having detailed protocols and a specific care plan intervention, staff never documented conducting the basic safety checks designed to protect this vulnerable resident.
The inspection found that R29 required partial assistance with basic movements like rolling in bed and transferring to chairs — activities that become more dangerous for residents with severe cognitive impairment who may not understand fall risks or call for help when needed.
Falls represent a leading cause of injury and death among nursing home residents, particularly those with dementia and cognitive decline. Hourly safety rounds serve as a fundamental intervention to monitor high-risk residents and prevent incidents that can result in fractures, head injuries, or other serious harm.
The resident's medical history included heart rhythm problems and high blood pressure requiring medications that can increase fall risk through dizziness or blood pressure changes. Combined with the severe cognitive impairment, these factors created a situation requiring vigilant monitoring.
Federal inspectors classified the violation as causing minimal harm but noted it affected the facility's ability to provide comprehensive, person-centered care as required by federal regulations. The finding suggests systemic problems with care plan implementation rather than an isolated documentation error.
The inspection occurred more than a month after the resident's discharge, indicating that other current residents may face similar gaps between written care plans and actual implementation of safety interventions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carlyle Senior Care of Fountain Inn from 2025-12-19 including all violations, facility responses, and corrective action plans.