Failure to Document and Report Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a nurse failed to follow professional standards and facility policy after a resident was found on the bathroom floor during the night shift. Although the certified nurse aide (CNA) reported the incident to the nurse, the nurse did not document the assessment, did not complete an incident report, and did not notify the oncoming shift nurse, physician, or the resident's family. The nurse also did not record any findings or actions in the resident's medical record, despite acknowledging that any time a resident is found on the floor, it is considered a fall according to facility policy. The resident involved had multiple medical diagnoses, including a recent humerus fracture, difficulty walking, anxiety disorder, chronic kidney disease, hypertension, chronic obstructive pulmonary disease, and hyperlipidemia. After being found on the floor, the resident initially reported no pain and declined having fallen, stating instead that they had slipped due to water on the floor. The CNA assisted the resident back to bed and informed the nurse, who performed a brief assessment but did not document it or initiate required post-fall protocols. Subsequent shifts were not informed of the incident, and the lack of documentation and communication led to a delay in recognizing the resident's injury. The following day, the resident complained of back pain and was eventually sent to the hospital, where imaging revealed a compression fracture in the thoracic spine. The facility's policies required documentation, incident reporting, and monitoring after any unwitnessed fall, none of which were completed by the nurse on duty at the time of the incident.