Failure to Notify Nurse and Assess Resident After Fall
Penalty
Summary
A deficiency occurred when facility staff failed to follow policy regarding the immediate assessment and notification of nursing staff after a resident fall. A certified nursing assistant (CNA) found a resident sitting on the floor in their room and, without notifying the nurse or requesting assistance, independently lifted the resident from the floor and assisted them back to bed. The CNA did not inform the nurse on duty about the fall at the time it was discovered, contrary to facility policy which requires immediate nurse notification and assessment before moving a resident post-fall. The resident involved was an older adult with a history of osteoarthritis and a recent diagnosis of a nondisplaced fracture of the right shoulder. The resident was cognitively intact and ambulatory, requiring stand-by assistance for showers. On the day of the incident, the resident was found on the floor by the CNA, who then lifted the resident without a nursing assessment. The resident subsequently complained of severe right arm pain and swelling, which was only communicated to the nurse after the resident was already back in bed. The nurse was not initially informed of the fall, but only of the resident's pain, and only learned of the fall and possible injury during the assessment prompted by the resident's complaints. Documentation and interviews confirm that the CNA acknowledged not following protocol, stating that the mistake was in transferring the resident post-fall without nurse notification or assessment. The nurse's assessment revealed a swollen, painful right arm, and the resident was sent to the hospital, where a closed fracture of the right shoulder was diagnosed. The failure to immediately notify the nurse and ensure a prompt assessment after the fall constituted a breach of facility policy and resulted in a delay in appropriate medical evaluation for the resident.