Failure to Follow Fall Protocols and Timely Notification After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with complex medical conditions, including end stage renal disease, hypertension, and metastatic cancer, experienced an unwitnessed fall with injuries. The resident was found on the floor by her bedside by two CNAs, who repositioned her back into bed without first notifying a nurse or having the nurse assess her for injuries. The nurse on duty, LVN A, subsequently assessed the resident in bed, noted abrasions to her knees, and provided basic first aid. However, LVN A did not initiate neurological assessments as required for unwitnessed falls with injuries, nor did she promptly notify the physician or the resident's representative as per facility protocol and policy. LVN A documented that she had notified the nurse practitioner and the resident's representative, but later admitted she had not actually done so at the time of the incident, only intending to call the nurse practitioner during business hours and leaving a message for the representative. The resident's representative was not informed of the fall until arriving at the facility later that morning, at which point the resident was found to be confused and injured. After the representative alerted another nurse, the resident was assessed and subsequently transferred to the hospital, where additional injuries, including rib fractures and significant changes in mental status, were identified. Interviews and record reviews confirmed that the facility's protocols required immediate assessment by a nurse after a fall, prompt notification of the physician and family, and initiation of neurological checks for unwitnessed falls or head injuries. The failure to follow these protocols, including the lack of timely notification and assessment, constituted noncompliance with professional standards of practice and the facility's own policies. The deficiency was identified as past noncompliance, with the Immediate Jeopardy period beginning on the date of the incident and ending several days later.