Failure to Immediately Assess Resident After Fall
Penalty
Summary
A deficiency occurred when a nurse failed to immediately assess a resident after a fall. The resident, who had multiple diagnoses including intellectual disabilities, dementia, osteoporosis, and a history of falls, was found on the floor in the dining room by a nurse who was not assigned to her care area. Instead of performing an immediate assessment, the nurse walked past the resident, who was alert and awake on the ground, and attempted to wake a nurse aide who was sleeping nearby. The nurse then instructed the aide to stay with the resident while she went to notify the assigned nurse. No assessment or assistance was provided by the first nurse at the time of discovery. The assigned nurse responded promptly upon notification and assessed the resident, who was found to have a large knot on her forehead and complained of left shoulder pain. A neurological check was performed before moving the resident, and the physician assistant was contacted, resulting in the resident being sent to the hospital. Hospital records later confirmed the resident sustained a frontal scalp hematoma and a non-operable clavicular fracture. The Director of Nursing confirmed that all staff are expected to provide care and attention to any resident in need, regardless of assignment.