Failure to Follow Protocol for Resident Fall Assessment
Penalty
Summary
The facility failed to provide adequate and appropriate health care by not ensuring that a resident was assessed immediately by a nurse after being found on the floor. The incident involved a resident who was originally admitted with diagnoses including flaccid hemiparesis affecting the right dominant side. On the day of the incident, the resident was assisted to the bathroom by two CNAs and left there for privacy. Shortly after, the resident was found on the floor by a housekeeper, and the CNAs lifted the resident back into a wheelchair before a nurse could perform an assessment. Interviews with staff revealed that the protocol requires a nurse to assess a resident before they are moved after a fall. However, in this case, the CNAs moved the resident without waiting for the nurse's assessment. The nurse, who was administering medication in another room at the time, assessed the resident only after the CNAs had already moved him. The Director of Nursing confirmed that CNAs are not allowed to move a resident after a fall until a nurse has conducted an assessment, which was not followed in this instance.
Plan Of Correction
D-Right to Adequate and Appropriate Health Care Immediate actions taken for residents found to have been affected: Resident #1 was discharged from the facility on. Identification of other residents having the potential to be affected: Residents within the past 30 days were reviewed to ensure they were evaluated by a licensed nurse prior to being moved to the bed or chair. No other residents were affected by the deficient practice. Actions taken/systems put into place to reduce risk of future occurrence: Staff Development Coordinator/designee will re-educate licensed clinical staff by on ensuring residents with are evaluated by a licensed nurse prior to the resident being moved to the bed or chair. How the corrective actions will be monitored to ensure the practice will not recur: DON/designee will review residents with weekly for 4 weeks then monthly x3 months to ensure residents are being evaluated by the nurse prior to being moved to the bed or chair. The administrator will oversee audit completion and report findings in the monthly Risk management/QA committee.