Delayed Reporting and Care Following Resident Fall
Penalty
Summary
A deficiency occurred when a certified nurse assistant (CNA) failed to immediately report a fall involving a resident with a history of cancer, impaired mobility, paraplegia, and a high risk for falls. The incident took place during a staff-assisted transfer from a wheelchair to a toilet, when the resident's knees buckled and he fell back into the wheelchair, resulting in complaints of back pain. The CNA did not notify the licensed nurse of the fall at the time it happened, and instead sought advice from another CNA, who incorrectly advised that if the resident did not end up on the floor, it was not considered a fall. The CNA completed the toileting and transfer without a nurse assessment and did not use a gait belt during the transfer, contrary to the resident's care plan requirements for two-person assistance and use of safety equipment. The resident continued to experience increasing back pain throughout the day, which was only reported to the nurse several hours after the incident. Upon assessment, the nurse documented moderate pain and administered pain medication. The physician was notified, and the resident was eventually transferred to the hospital more than five hours after the initial fall. Hospital evaluation revealed new compression fractures in the thoracic spine, and the resident was prescribed a back brace and follow-up care. The delay in reporting and assessment resulted in a delay in necessary medical treatment for the resident's injuries. Facility policy required that all falls be immediately reported to a licensed nurse, with prompt assessment and notification of the physician and family, especially in cases of suspected fracture. Interviews with staff and review of documentation confirmed that the CNA did not follow these procedures, and the incident was not reported or assessed in a timely manner. The Director of Nursing verified that the fall should have been reported immediately and that the investigation into the incident was still ongoing at the time of the survey.