Video footage captured the moment Certified Nursing Assistant A discovered the resident on the floor with their left arm resting on the bed. "Oh he/she is on the floor. Did you hit your head? How did you fall out," the assistant said on the recording.
But no fall report was ever filed.
The resident had been recovering from right femur fracture surgery performed just four days earlier on December 17. Medical records showed diagnoses of late-onset Alzheimer's dementia with behavioral disturbances, short-term memory loss, muscle weakness, and a history of falls.
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 "unless there is evidence suggesting otherwise, 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.
The policy requires that "resident's physician shall be informed of any event concerning the physical care and wellbeing of the resident" and "family or power of attorney shall be informed of all events defined in this policy."
None of that happened.
When investigators interviewed CNA A two days later, the assistant said they discovered the resident "with their elbows resting on the bed and buttocks off the floor." The assistant told the resident to sit down onto the floor so they could help them up. "He/she does not consider it a fall and did not report it as a fall," according to the inspection report.
A second nursing assistant, CNA B, followed the first assistant into the room and also saw the resident sitting on the floor. The resident denied falling when asked. CNA B told investigators they didn't consider it a fall either, calling it "just a slide off the bed." They didn't know if any report was completed.
The facility's Director of Nursing and Executive Director disagreed with their staff's assessment. When interviewed by inspectors, both administrators said they "would consider a resident sliding off the bed onto the floor and a resident holding themselves up by their elbows off the floor as a fall and should be reported."
They 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 resident's medical record contained no documentation of any fall on December 21. There was no record that the physician had been notified. No documentation that family members were contacted.
The facility's Event Reporting Policy emphasizes that documentation is "essential to providing resident and client care." It defines reportable events as those "outside of usual or normal happenings and present a potential liability" or those "not in keeping with standards, policies, procedures or practices and may have an adverse outcome."
The policy specifically addresses falls, noting that "a fall without injury is still a fall" and that even episodes where residents lose balance but are caught by staff intervention count as falls.
For a resident recovering from recent femur surgery, any unplanned contact with the floor represents a significant safety concern. The resident was on "weight bearing as tolerated" status following the December 17 surgery, meaning their mobility was already compromised.
Federal inspectors cited the facility for failing to immediately notify the resident's doctor and family member of the situation, as required by regulations. The violation affected few residents but carried potential for actual harm.
The 67-bed facility disputed the citation.
The inspection was conducted in response to a complaint filed with state regulators. Investigators reviewed video evidence, medical records, and facility policies before interviewing multiple staff members about the incident.
The case illustrates how staff interpretations of what constitutes a "fall" can lead to gaps in required notifications. While the nursing assistants saw a resident who had "slid" from bed to floor, facility leadership recognized the same scenario as a reportable fall requiring immediate family and physician notification.
The resident's complex medical history, including recent major surgery, Alzheimer's dementia, and previous falls, made prompt communication about any floor contact particularly important for ongoing care decisions.
The facility's own policy provided clear guidance that finding a resident on the floor without a witnessed explanation should trigger fall protocols. The video evidence showed staff acknowledging the resident had ended up on the floor in an unplanned way, asking directly "How did you fall out."
Yet the disconnect between frontline staff assessment and administrative expectations meant the resident's family remained unaware of the incident. The attending physician, responsible for post-surgical care and fall risk management, was never informed.
The violation occurred nearly two weeks after the resident's femur surgery, during a critical recovery period when any additional trauma or mobility concerns would be medically significant.
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.