La Bella Of Danville

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

bed and railing and could not find his call light. There was no signage in Resident R5's room reminding Resident R5 to use his call light. On 11/19/25 at 12:37 PM V32 RN stated Resident R5 tries to self-transfer and Resident R5's fall interventions include fall mat, frequent toileting and keeping Resident R5 busy with activities. V32 stated most of Resident R5's falls have happened when Resident R5 was trying to fix something and Resident R5 has behaviors of putting himself on the floor. V32 stated the care plan documents resident fall interventions. V32 stated Resident R5 does use his call light, and it should be within reach. V32 entered Resident R5's room and removed Resident R5's call light from his dresser and applied it to Resident R5's bed rail. V32 stated Resident R5 has not gotten out of bed yet today and his call light should be clipped to his bed or attached to the bedrail. At 2:34 PM V32 stated if Resident R5 is found on the floor but not witnessed by staff to intentionally place himself on the floor, then it is considered a fall. V32 was asked about Resident R5's 9/5/25 Nursing Note. V32 stated since Resident R5 was found sitting on the fall mat, V32 did not consider it to be a fall and therefor did not notify Resident R5's family or physician. V32 confirmed staff did not witness Resident R5 place himself on the floor mat. On 11/19/25 at 12:59 PM V28 CNA stated Resident R5 has confusion and attempts to self-transfer more so out of the wheelchair than his bed, and Resident R5 requires limited assist of one staff person for transfers. Resident R5 does use his call light and does not have a sign to remind Resident R5 to call don't fall. V28 entered Resident R5's room and confirmed there were no signs posted to remind Resident R5 to use his call light. V28 stated V28 would look at the care plan/Kardex to determine fall interventions.On 11/20/25 at 9:00 AM V34 Licensed Practical Nurse stated Resident R5 had an unwitnessed fall during the early morning on 10/5/25. V34 stated an unidentified CNA heard a noise and found Resident R5 sitting on the floor mat next to his bed. V34 stated Resident R5 was confused and could not say why Resident R5 was trying to get up. V34 stated V34 last saw Resident R5 in bed shortly before the fall occurred but was unsure

the time that Resident R5 was last toileted. V34 said, About 30 minutes later we noted swelling to (Resident R5's) arm, notified

the physician and sent (Resident R5) to the hospital for x-rays. On 11/9/25 at 3:09 PM V2 DON stated V2 was unsure which CNA found Resident R5 on the floor on 10/5/25. V2 stated when Resident R5 resided in the South building, Resident R5 wouldn't wait for staff assistance to get changed or toileted, and V2 had to assist Resident R5 at times. V2 confirmed all Resident R5's 10/5/25 fall investigation documentation was provided. V2 stated he interviews staff for unwitnessed falls to see when residents were last checked on and toileted prior to the fall but does not always have documentation of this. V2 confirmed this information was not documented for Resident R5's 10/5/25 fall. V2 stated if

we know a resident has a behavior of putting themself on the floor but we don't see it happen, then it should be considered a fall. V2 confirmed falls should be reported to the physician and family. V2 stated neurological checks should be done for unwitnessed falls. On 11/20/25 at 10:30 AM V2 stated V2 spoke with staff regarding Resident R5 being found on the floor on 9/5/25 and reviewed the nursing note. V2 stated Resident R5 was found on the mat with his knees up and Resident R5 denied that he had fallen. V2 stated Resident R5 told staff he was cleaning the baseboard and Resident R5 is care planned for putting himself on the floor. V2 stated this was not considered to be a fall. V2 confirmed Resident R5 was not witnessed putting himself on the floor, this was not investigated, and no new interventions were developed. V1 Administrator confirmed it could not definitively be determined that Resident R5 did not truly fall since this was not witnessed. V3 Assistant DON stated Resident R5's confusion waxes and wanes, with some days being better than others. The facility's Managing Falls and Fall Risk policy, dated March 2018, documents unless there is evidence otherwise, when a resident is found on

the floor it should be considered a fall. This policy documents staff and the physician will give input to develop and implement a resident centered fall prevention plan and implement additional interventions if falling recurs. This policy documents staff will re-evaluate the situation and whether to continue or change interventions.

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