Bria Of Godfrey

residents into the bed and call light placed in reach.

Resident seen in ER and treated for Un-witnessed fall, Abnormal CT-Scan, Closed FX (fracture) of multiple ribs on right side, Closed non-displaced Fx of right clavicle, Stercoral colitis, constipation and Acute UTI (urinary tract infection).

Resident has new orders for ABT (antibiotics) from ER (emergency room).

Discoloration noted to UE (upper extremity).

Resident tearful during assessment and PRN (as needed ) pain medication given for discomfort. On 12/3/2025 at 6:25 AM, V7, Certified Nursing Assistant (CNA), stated she usually works midnights. R2 fell in the dining room. I did not witness it but heard she had fallen but she passed away yesterday. If a resident falls, we are supposed to get help and tell the nurse.

The nurse will then tell us what to do. I am not sure why (R2) was moved. On 12/4/2025 at 1:29 PM, V8, Certified Nursing Assistant (CNA), stated, If a resident falls, we are supposed to get help and tell the nurse before moving them because we could make it worse if we moved them and they were injured. On 12/4/2025 at 4:14 PM, V14, Licensed Practical Nurse (LPN) stated, If a resident falls, staff are to yell for help and wait for nursing to assess them. If we think there may be an injury, we notify the doctor and send them out.

Staff are never to get any resident up without them being assessed first. If they try and get someone up they could easily injure them. On 12/8/2025 at 1:11 PM, V2, Director of Nursing (DON), stated, I know the previous DON was walked out of the building, but I am not sure what went down.

Today, is my first day. If a resident falls, I would expect staff to yell for help, nursing to assess the resident, and if there are any injuries or possible injuries to notify the physician to send them out to the hospital. I would never expect staff to get them up without assessing them and/or notifying nursing and/or are being monitored by staff. On 12/17/2025 at 3:38 PM, V23, Medical Doctor, stated, If a resident had a fall, I would expect nursing staff to be contacted so they could assess the resident look for possible injury and depending on the nature of the injury that would determine what staff to do next. In this case, (R2) did have a fracture and injury so this is something staff need to know that there was fall. On 12/19/2025 at 12:10 PM, V24, Infection Control Nurse, stated, I did speak with someone from the hospital. We went back and looked at the cameras, and it was not a medical assistant that found (R2), it was actually a CNA (V25). I am not sure what happened and why no management knew (R2) had fallen until the next day. On 12/19/2025 at 12:10 PM, V25, CNA, stated, I was in the dining room feeding another person.

When I looked over, I saw a (geriatric chair) sitting at the table with no resident. I thought it was odd and when I stood up (R2) was under the table. I was trying to get staff attention and there was an agency nurse there and I thought she saw her under the table.

The Facility Fall Prevention and Management Policy, with a revision date of 9/2025, documents, This facility is committed to maximizing each resident's physical, mental and psychosocial well-being.While preventing all falls is not possible, the facility will identify and evaluate those residents at risk for falls, plan for preventive strategies, and facilitate as safe an environment as possible.

All resident fallsshall be reviewed, and the resident's existing plan of care shall be evaluated and modified as needed.

Evaluate the resident for any injury and notify the physician and emergency contact.

Complete a fall incident report in the (Computer) risk management portal.

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