Failure to Ensure Nursing Staff Competency in Resident Assessment After Injury and Elopement
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary knowledge and competencies to initiate appropriate clinical responses during resident care, as evidenced by the care of one resident with severe cognitive impairment and multiple medical conditions. The resident required substantial to maximum assistance with transfers and ambulation, had a history of falls, dementia, and used a wander/elopement alarm. Despite these needs, the clinical record showed that when facial bruising was first observed on the resident, staff did not perform a comprehensive head-to-toe assessment or initiate neurological checks, as would be expected following an unexplained injury. Additionally, after the resident eloped from the facility and was subsequently found, staff again failed to conduct a thorough nursing assessment or neurological checks within an hour of the incident. Interviews with nursing staff revealed a lack of awareness regarding the need for such assessments following incidents of injury or elopement. One nurse assumed the bruising had already been addressed and did not further assess the resident, while another was unaware of the requirement to perform a head-to-toe assessment after the resident was found outside the facility. The facility did not have a policy in place regarding the completion of nursing head-to-toe assessments or neurological checks, although the Missing Patient Response Plan instructed staff to examine the patient and document findings. The absence of clear protocols and staff knowledge led to incomplete assessments and documentation following significant events involving the resident.