Failure to Timely Assess and Treat Resident After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident experienced an unwitnessed fall with injury, and the facility failed to provide a timely assessment and necessary treatment. The incident began when a CNA observed the resident on the floor in front of her wheelchair and notified an RN. However, the RN did not assess the resident or provide needed treatment at that time. The CNA, after waiting for the nurse, assisted the resident back into her wheelchair without a nursing assessment, and there was no documentation of the fall or any assessment in the medical record for that date. Following the fall, the resident, who had a history of dementia, Alzheimer's disease, repeated falls, and was receiving hospice care, complained of hip pain and exhibited decreased mobility. Despite these symptoms, the resident was not transferred to the emergency room until two days later, after further assessment revealed significant pain and physical changes, including a leg length discrepancy. X-rays subsequently confirmed an acute right hip fracture, and the resident was then transferred to the hospital for treatment. Interviews and record reviews confirmed that the facility's fall policy, which required immediate assessment and notification of the physician and family, was not followed. The RN did not assess the resident after being notified of the fall, and the incident was not documented in the medical record. The lack of timely assessment and intervention resulted in a delay in necessary treatment for the resident's injury.