Failure to Complete Post-Fall Monitoring and Communicate Fall to Dialysis Center
Penalty
Summary
The facility failed to ensure proper post-fall monitoring and communication for a resident who experienced a fall resulting in a head injury. After the fall, neurological checks were initiated, but the facility did not accurately complete these checks for the full 72-hour period as required by protocol. Specifically, neurological assessments were missed while the resident was out of the facility for dialysis and after transfer to an acute care hospital. Additionally, the log for neurological checks did not cover the full 72-hour period and was not scheduled accurately. The Director of Nursing confirmed that the post-fall neurological checks were not completed as per facility protocol when the resident returned from dialysis. Furthermore, the facility did not communicate the resident's fall to the dialysis center, despite having a process in place to send pre-dialysis assessment forms with the resident. The form sent on the day of the fall did not indicate that the resident had experienced a fall, and there was no documentation showing that the dialysis center was informed. This lack of communication meant the dialysis center was not aware of the need for continued monitoring for fall-related injuries during the resident's treatment. The resident was later transferred to an acute care hospital and diagnosed with a thoracic vertebrae fracture.