Failure to Follow Protocol After Resident Fall with Head Injury
Penalty
Summary
Staff failed to follow professional standards of care after a resident with dementia, heart failure, and severe cognitive impairment experienced a witnessed fall with a head injury. The resident, who was known to be at risk for falls and had a history of recent illness, was observed by a nurse aide to become dizzy, spin, and fall, striking their head on the floor. Following the fall, the resident exhibited altered mental status, was unable to follow commands, and staff were unable to obtain vital signs. Despite these significant changes in condition and the presence of a head injury, the supervising RN directed staff to move the resident from the floor into a wheelchair and then into bed, rather than leaving the resident in place and awaiting EMS as per standard protocols for suspected head or spinal injury. Multiple staff, including an LPN and the APRN, later acknowledged that the resident should not have been moved given the circumstances. Facility policy and medical references reviewed also indicated that residents with head injuries and neurological compromise should not be moved and should be referred immediately for emergency care. The resident was eventually transferred to the hospital by EMS after oxygen was applied, but expired a few hours later. Documentation and interviews confirmed that the decision to move the resident was made by the RN, and that other staff present did not question this directive, despite recognizing it was not consistent with best practice or facility policy for post-fall care involving head injury and altered mental status.