Failure to Follow Post-Fall Protocols Resulting in Delayed Diagnosis of Injuries
Penalty
Summary
The facility failed to provide necessary care and services according to its fall policies and procedures for a resident who experienced an unwitnessed fall. The resident, who had a history of Parkinson's disease, moderate cognitive deficits, and required maximum assistance with transfers, was left unattended on the toilet and subsequently fell into the bathtub. After the fall, the resident experienced rib pain and was found by staff in the bathtub, but immediate post-fall assessments, including neurological checks, were not performed as required by facility policy. Interviews and record reviews revealed that staff did not initiate post-fall neuro-checks or notify the resident's physician and responsible party immediately after the incident. Instead, these actions were delayed until the following day, despite the resident exhibiting pain and bruising in the rib area. The facility's fall management policy required neurological checks for 72 hours following an unwitnessed fall or suspected head injury, as well as prompt notification of the physician and responsible party, but these procedures were not followed. The delay in post-fall care and assessment resulted in a delayed diagnosis of multiple rib fractures for the resident. Staff interviews indicated confusion or misinformation regarding post-fall protocols, with one nurse stating that the previous DON had advised that post-fall procedures were not necessary in such cases. The current DON confirmed that the expected protocol was not followed, which contributed to the delay in identifying and treating the resident's injuries.