Failure to Assess Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident was assessed immediately by a nurse after being found on the floor by facility staff. The incident involved a resident with a history of significant medical conditions, including subcortical and flaccid paralysis affecting the right dominant side. On the day of the incident, the resident was placed on the toilet by two CNAs and left alone for privacy. Shortly after, the resident was found on the floor by a housekeeper, and the CNAs assisted the resident back into a wheelchair without waiting for a nurse to conduct an assessment. Interviews with staff revealed that the nurse, who was administering medication in another room, was informed of the incident after the CNAs had already moved the resident. The nurse assessed the resident only after the CNAs had placed the resident in a wheelchair. Facility protocol dictates that CNAs should notify a nurse immediately and wait for an assessment before moving a resident who has fallen. The Director of Nursing and other staff confirmed that the CNAs did not follow the required protocol, which includes notifying the nurse, conducting an assessment, and completing an incident report before moving the resident.
Plan Of Correction
F 684 D- Quality of 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.