Briarfield Manor

Review of the fall risk assessment data 04/14/25 revealed Resident #72 was at moderate risk for falls.

Review of the comprehensive MDS assessment dated [DATE] revealed Resident #72 was moderately cognitively impaired.

She required supervision for eating oral and personal hygiene and partial to moderate assistance with toileting and showering.

She was occasionally incontinent of urine and bowel.

Review of the care plan dated 04/21/25 revealed Resident #72 was at risk for falls due to muscle weakness, history of falls, and difficulty walking.

Interventions included ensuring the call light was within reach, maintaining a clear pathway and two quarter top positioning bars when up in bed to aid in positioning.

Review of the nursing note dated 05/15/25 at 3:00 P.M. revealed Resident #72 was found on the floor in front of her wheelchair in her room.

She said she was attempting to self-ambulate and was unable to keep her balance.

She said she hit her head on the floor. A red area to her left hip and left upper head were noted.

Here vital signs were noted to be within normal limits; however, they were not documented.

The resident was assisted to her wheelchair, and her physician, the DON and daughter were notified.

Her daughter asked that the resident be sent to the ED.

Review of the facility incident report dated 05/15/25 revealed Resident #72 was attempting to self-ambulate when she lost her balance, there was an alarm (no order for an alarm) sounding at the time of the incident.

The resident was assessed and both neurological checks and vital signs were stated to be within normal limits; however, neither were included in the report. Resident #72 was listed as confused but oriented to person.

Predisposing factors were listed as weakness, gait imbalance and ambulating without assistance.

The investigation revealed no evidence of the residents' call light being in reach.

Review of the nursing note dated 07/11/25 at 10:58 A.M. revealed Resident #72 was found on the floor with no signs of injury.

The resident was confused and unable to answer questions, could not follow the light with her eyes.

The resident was sent to the ED, and both her daughter and son were notified as well as the physician and DON.

Review of the facility incident report dated 07/11/25 revealed Resident #72 was found on the floor by LPN #205 and was assisted into her wheelchair along with an unnamed CNA. A skin assessment was completed, and no visible signs of injury were noted.

The resident could not indicate if she hit her head but was unable to answer questions or follow direction.

The resident's vital signs were obtained with a blood pressure of 116/70, pulse ox 99%, temperature 97.9 degrees F, heart rate 80, and no pain.

Neurological checks were reported as within normal limits; however, there was no documented evidence of the neurological checks.

The resident was sent to the ED for an evaluation.

The resident was confused with predisposing factors of incontinence, gait imbalance and not using her call light for assistance.

The investigation did not reveal if the resident's call light was within reach or when she was last toileted.

Interview on 08/25/25 at 12:14 P.M. with the DON revealed Resident #72 had no physician's order or care plan addressing a bed or chair alarm.

She verified the facility's fall investigations likely needed to be updated to ensure accuracy and thoroughness and should have included all interventions in place at the time of the falls for Resident #72 to determine a root cause of the fall.

Review of the undated facility policy titled Fall Prevention Procedure/Policy revealed the facility would document and evaluate any fall that occurred while the patient resided at the facility including when and where and observations of the event.

The facility would assess, and document vital signs, recent injuries, neurological status, precipitating factors and details of how a fall occurred.

The nurse would assess the patients' vital signs, range of motion and any injuries as well as identify environmental factors that may have contributed to the fall.

This deficiency represents noncompliance investigated under Complaint Number 2584229.

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