Failure to Timely Assess and Document Resident Injury After Assisted Fall
Penalty
Summary
A deficiency occurred when staff failed to immediately assess and document appropriate interventions for a resident who was lowered to the floor and sustained an abrasion to her back. The resident, who had intact cognition and required substantial to maximal assistance with mobility and transfers, attempted to self-transfer from the toilet to her wheelchair. During this attempt, her knees buckled and a CNA assisted her to the floor to prevent a fall, resulting in a back abrasion. The CNA observed bleeding skin tears and attempted to notify the nurse, but there was a significant delay in the nurse's response. Multiple staff interviews confirmed that the nurse did not promptly respond to the incident, with reports indicating a wait time of 10 to 40 minutes before the nurse arrived to assess the resident. During this period, CNAs moved the resident from the floor to her wheelchair without a nursing assessment. The nurse, when she did arrive, did not immediately assess the resident's back injury and later admitted to forgetting to complete the assessment after the resident was put to bed. The initial documentation and assessment of the abrasion did not occur until the following day, despite the injury being visible and reported at the time of the incident. The resident's clinical record indicated a history of falls and multiple diagnoses, including hypertension, diabetes, and mental health conditions. Despite these risk factors and the facility's policy requiring immediate assessment after incidents or changes in condition, the required head-to-toe assessment and documentation were not completed in a timely manner. The delay in assessment and failure to follow protocol were acknowledged by the Director of Nursing and confirmed through staff interviews and record review.