Failure to Conduct RN Assessment After Resident Fall
Penalty
Summary
The facility failed to ensure that an assessment was completed by a registered nurse after an injury occurred to a resident. According to the Pennsylvania Code and the facility's policy, a registered nurse is required to assess any injuries following an incident, such as a fall. However, in the case of Resident 2, who was moderately cognitively impaired and required supervision for ambulation and transfers, there was no documented evidence of a registered nurse assessment after the resident fell on December 6, 2024. The fall occurred when the resident attempted to sit in front of the piano but missed the stool and landed on the floor. Licensed Practical Nurse 2, who witnessed the fall, confirmed that no registered nurse assessment was conducted. The Director of Nursing also confirmed the lack of documentation for a registered nurse assessment and attributed the oversight to staffing shortages, as she had been covering shifts in addition to her regular duties. This failure to conduct a proper assessment by a registered nurse after the fall was a violation of the professional standards required by the facility's policies and state regulations.
Plan Of Correction
Resident 2 suffered no ill effects as a result of failure to document the Registered Nurse assessment. Education for Registered Nurses and Licensed Practical Nurses will be conducted on 1/14/2025 regarding documentation of the Registered Nurse assessment. Review of change in condition will occur during the clinical portion of the Interdisciplinary Team meeting to ensure appropriate registered nurse assessments occurred appropriately and timely. Weekly audits for accuracy by the Director of Nursing or designee will be conducted weekly, and the results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.