Failure to Follow Fall Management Protocols Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to ensure a resident received treatment and care in accordance with professional standards and the resident’s care plan. The resident, an elderly female with a history of cerebrovascular disease and right-sided hemiplegia, was dependent on staff for activities of daily living, including bed mobility and transfers. During the provision of perineal care, the CNA assisted the resident in turning and repositioning in bed. The resident’s legs became misaligned, and after the CNA removed the fitted bed sheet, the resident’s legs dangled off the bed, leading to her falling to the floor. The incident was captured on in-room surveillance video, which showed the resident hitting her head and sustaining a fall after the CNA stepped away from the bedside. Following the fall, the CNA immediately picked up the resident from the floor and placed her back on the bed without waiting for a nurse to perform a head-to-toe assessment, as required by facility protocol. The charge nurse was notified after the resident had already been moved, and upon arrival, found the resident on the bed rather than on the floor. The nurse questioned the CNA about moving the resident, emphasizing that residents who have fallen should not be moved prior to a nursing assessment to prevent exacerbation of potential injuries. The nurse conducted an assessment and, due to the unwitnessed nature of the fall, sent the resident to the emergency room for further evaluation. Medical records from the hospital revealed the resident sustained a nondisplaced right femur fracture and a dislodged feeding tube as a result of the fall. The resident required nonsurgical management of the fracture and the use of a Hoyer lift for transfers. The facility’s policy on post-fall procedures required staff to evaluate for injuries and obtain vital signs before moving a resident, which was not followed in this case. The CNA involved had received relevant in-service training and competency assessments prior to the incident, but failed to adhere to established protocols during the event.