Failure to Timely Initiate Post-Fall Procedures and Documentation
Penalty
Summary
The facility failed to follow its Fall Management Program policy and procedure for one resident who experienced a fall. According to the facility's policy, after a resident falls, the Licensed Nurse (LN) is required to perform a post-fall evaluation, notify the Physician, Director of Nursing (DON), and responsible party, and initiate a Post-Fall Huddle within 15-20 minutes. This huddle should include updating the care plan, interviewing witnesses, and documenting the incident in the medical record. However, for this incident, the required post-fall documentation was not initiated until two days after the resident's fall. The resident involved had a history of dementia and a recent right hip fracture that required surgery. The fall occurred at 10:00 pm, but there was no documentation or notification of the event until two days later. The care plan reflecting the actual fall was not initiated until three days after the incident. Interviews with staff revealed that the LN on duty did not document the fall or notify the appropriate parties as required by policy. The DON and Administrator confirmed that the fall was not reported or documented in a timely manner. Further review and interviews indicated confusion among staff regarding the timing and responsibility for post-fall assessment and documentation. The LN on duty at the time of the fall stated that he was not aware of the incident until days later and did not perform or document the required assessment. The oncoming nurse reportedly handled the situation, but the necessary documentation and notifications were not completed as outlined in the facility's policy.