Failure to Immediately Notify Nurse and Assess Resident After Fall
Penalty
Summary
A direct care staff member (CNA) failed to follow facility policy and procedures by not immediately notifying a nurse after a resident experienced a fall in the shower room. The CNA assisted the resident, who has a history of cerebral infarction, hemiplegia, and moderate cognitive impairment, with a shower. During the process, the resident slid off the shower chair after attempting to sit down while still soapy. The CNA picked the resident up and returned him to the chair without calling for a nurse or conducting an immediate assessment as required by facility policy. The CNA asked the resident if he wanted the incident reported, but the resident declined. The CNA then continued with the shower, dressed the resident, and returned him to his room, again asking if he wanted the fall reported, to which the resident again said no. The CNA did not inform the nurse on duty about the fall and proceeded with other duties. The incident was only discovered later in the day when the resident told his sister, who then informed the evening nurse. The nurse subsequently assessed the resident and found no injuries. Facility policy requires that after a fall, the CNA must call for a nurse immediately and not move the resident until assessed. The nurse on duty during the morning shift was not made aware of the fall, and the required immediate assessment did not occur. The resident's care plan identified him as at risk for falls due to his medical conditions and need for assistance with transfers and showers. The delay in notification and assessment constituted a failure to provide appropriate treatment and care according to orders and the resident’s needs.