Video footage captured the moment Certified Nursing Assistant A approached the resident and asked, "Oh he/she is on the floor. Did you hit your head? How did you fall out."
Despite using the word "fall" in the moment, the CNA later told inspectors on December 23 that he discovered the resident "with their elbows resting on the bed and buttocks off the floor." He told the resident to sit down onto the floor so he could help them up.
"He does not consider it a fall and did not report it as a fall," inspectors wrote.
The resident had undergone right femur fracture surgery just four days earlier on December 17. Their medical record listed diagnoses including short-term memory loss, muscle weakness, and a recent fall.
Lutheran Senior Services at Meramec Bluffs' own policy, revised in July 2021, defines a fall as "an unintentional coming to rest on the ground, floor, or other lower level." The policy specifically states that "a fall without injury is still a fall" and that "when a patient or resident is found on the floor, and there is no witness to account for the event" it should be considered a fall unless evidence suggests otherwise.
A second nursing assistant, CNA B, followed the first aide into the room and also saw the resident on the floor. The resident denied falling when asked.
CNA B told inspectors he "does not consider this a fall, just a slide off the bed." He said he didn't know if any report was completed.
No documentation of the December 21 incident appears in the resident's progress notes. The physician and next of kin were never notified.
The facility's event reporting policy requires that "resident's physician shall be informed of any event concerning the physical care and wellbeing of the resident" and that "family or power of attorney shall be informed of all events defined in this policy."
When inspectors interviewed the Director of Nursing and Executive Director on December 23, both administrators said they would consider a resident sliding off a bed onto the floor as a fall that should be reported. They also said a resident holding themselves up by their elbows while off the floor constitutes a fall.
The administrators confirmed that facility protocol requires notifying the physician, next of kin, and either the Director of Nursing or Administrator whenever a fall or incident occurs.
The 67-bed facility's event reporting policy emphasizes that documentation "is essential to providing resident and client care" for events that are "outside of usual or normal happenings and present a potential liability."
Federal inspectors cited the facility for failing to immediately notify the resident's doctor and family member of situations that affect the resident, as required by nursing home regulations.
The facility is disputing the citation.
The resident's complex medical history included recent surgery and multiple risk factors for falls, including Alzheimer's dementia with behavioral disturbances, short-term memory loss, and documented muscle weakness. Their weight-bearing status was listed as "as tolerated" following the femur fracture surgery.
The inspection was conducted in response to a complaint. Lutheran Senior Services at Meramec Bluffs, located on Meramec Trails Drive, serves residents in the St. Louis metropolitan area.
The video evidence directly contradicted both nursing assistants' characterizations of the event. While CNA A asked the resident "how did you fall out" in the moment, both staff members later described the incident as something other than a fall when questioned by inspectors.
The disconnect between facility policy, administrator expectations, and front-line staff implementation highlights gaps in training or communication about incident reporting requirements.
For families of nursing home residents, the failure to receive timely notification about incidents involving their loved ones can prevent them from making informed decisions about care or seeking additional medical evaluation when needed.
The resident's recent surgery and multiple fall risk factors made prompt reporting particularly important for ensuring appropriate medical follow-up and fall prevention measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lutheran Senior Services At Meramec Bluffs from 2025-12-29 including all violations, facility responses, and corrective action plans.