Failure to Follow Fall Protocol and Medication Review After Unwitnessed Fall
Penalty
Summary
The facility failed to follow its fall clinical protocol for one resident who experienced an unwitnessed fall. According to staff interviews and record review, the resident was found sitting on the floor next to his bed early in the morning. Immediate assessment was performed, including checking vital signs, and the resident was assisted back to bed. The resident was severely cognitively impaired, with a history of cerebrovascular accident resulting in right hemiparesis, and was at high risk for falls as documented in his care plan. Despite the facility's protocol requiring assessment and documentation of all current medications, especially those associated with increased risk of bleeding, there was no evidence that the resident's use of antiplatelet medication was considered or communicated to the physician at the time of the fall. The primary physician later stated that, had he been informed of the resident's antiplatelet use and the unwitnessed nature of the fall, he would have ordered a CT scan due to the risk of internal bleeding, even though the resident's vital signs were stable. The protocol also required a thorough head-to-toe assessment and monitoring for signs of injury, which was not fully documented in the records reviewed. Staff interviews revealed inconsistent understanding and application of the fall protocol, particularly regarding the need to review medications and communicate relevant information to the physician. The facility's failure to follow its own clinical protocol for falls, including comprehensive assessment and communication, resulted in a deficiency related to providing appropriate treatment and care according to orders, resident preferences, and goals.