Failure to Report and Assess Resident Fall
Penalty
Summary
The facility failed to provide timely assessment and treatment for a resident who experienced an unwitnessed fall. The resident, who had diagnoses including Parkinson's Disease, Dementia, and Diabetes Mellitus, was at risk for falls and required moderate assistance for activities of daily living. On the date of the incident, the resident was found on the floor by a Food Service Worker, but the fall was not reported by the Certified Nurse Aide (CNA) and Licensed Practical Nurse (LPN) involved. Consequently, the resident was not assessed or treated immediately after the fall. The facility's policy required staff to notify a licensed nurse if a resident sustained an accident or injury of unknown origin. However, the CNA and LPN involved did not report the fall to the nursing supervisor or conduct an assessment. The resident was only transferred to the hospital the following day after a bruise was noted on their back, where it was discovered that the resident had sustained a fractured scapula and fractured ribs. Interviews with the staff revealed that the CNA and LPN initially denied the occurrence of a fall but later admitted to assisting the resident off the floor without notifying the supervisor. The Director of Nursing confirmed that the resident was moved before an assessment was conducted, leading to a delay in treatment. The medical doctors involved stated that the resident should have been assessed immediately and that earlier notification could have expedited hospital transfer and treatment.
Plan Of Correction
Plan of Correction: Approved March 10, 2025 1. The specific description of the action/activities to be taken in order to achieve correction for the residents found to have been affected by the deficient practice is: To achieve correction for the resident found to be affected by the deficient practice, in-services were provided to all licensed nurses that if observe a resident who has sustained an accident/injury of unknown origin, they must promptly notify the nursing supervisor on duty. All staff will also receive mandatory training on the policy Resident Incident/Accident Reporting and Investigation Process. 2. How will The New Jewish Home (NAME) Neuman identify other residents having the potential to be affected by the same deficient practice (and implementation of action as in #1 above)? All residents have the potential to be affected by the same deficient practice. 3. What measures will be put into place or systemic changes made to ensure the deficient practice will not recur? Policy was reviewed and found to be in compliance. Education to nursing staff regarding the purpose of incident reporting. Appropriate and immediate interventions are implemented, and corrective actions are taken to minimize negative outcomes and prevent reoccurrence. Incidents and accidents will be reviewed during nursing huddle to identify any missing responses to incidents. 4. How will The New Jewish Home (NAME) Neuman monitor its corrective action to ensure the deficient practice being corrected will not recur? Audits will be done weekly for one month and monthly for three months by the Director of Nursing or Designee. All results from the audits completed will be reported to the QAPI committee for three months for appropriate action.