Failure to Document RN Assessment After Resident Fall
Penalty
Summary
A deficiency was identified when a Registered Nurse (RN) failed to document an assessment of a resident after the resident experienced a fall. The incident involved a resident with diagnoses including age-related osteoporosis and mild cognitive impairment, as evidenced by a Brief Interview for Mental Status score indicating severely impaired cognition. The fall was documented in the medical record by an LPN, and both the incident/accident report and the facility's investigation worksheet were completed and signed by the LPN. There was no evidence in the electronic medical record that an RN assessed or documented an assessment of the resident following the fall. Interviews with facility staff revealed that the standard practice was for the nurse assigned to the resident, typically an LPN, to complete all incident documentation, and that RNs or supervisors did not document their assessments in the electronic medical record or on any separate form. The Director of Nursing confirmed that while RNs were expected to assess residents after a fall, they were not required to document these assessments. Additionally, the facility's fall assessment and management policy did not specify that RN documentation was required after a resident sustained a fall.