Failure to Complete Post-Fall Assessments and Notifications
Penalty
Summary
The facility failed to provide necessary care and services to prevent further falls and injuries for two of four sampled residents. For one resident with severe cognitive impairment, after a fall from bed resulting in a minor injury, there was no documentation of post-fall neurological assessment or monitoring. Additionally, the attending physician and responsible party were not notified of the incident, contrary to facility policy. Interviews with staff revealed that the licensed nurse was not informed of the fall by the CNAs, and as a result, required assessments and notifications were not completed or documented. For another resident, who was cognitively intact and had clear speech, a witnessed fall occurred in which the resident struck her face. The neurological assessment post-fall documented abnormal findings, including unequal and non-reactive pupils, inability to respond to commands, and slurred speech. Despite these findings, the post-fall assessment was incomplete, and the resident was not transferred via paramedics as required by facility policy for abnormal neurological findings. Documentation of contributing factors, medication changes, and clinical suggestions was also incomplete. Facility policies reviewed indicated that after any fall, a licensed nurse must perform a post-fall evaluation, complete neurological checks for 72 hours, and notify the attending physician and responsible party. Staff interviews confirmed that these steps were not followed for both residents. The failures in assessment, documentation, and notification posed a risk that residents would not receive timely interventions to address their post-fall status.