Failure to Assess and Notify After Resident Found on Floor Mattress
Penalty
Summary
The facility failed to provide necessary care and services to prevent a fall incident for one of seven sampled residents. Specifically, when a resident with a history of falls and requiring substantial assistance for mobility and toileting was found lying on a floor mattress, the facility did not follow its own policies for post-fall assessment and notification. The facility's policies require that after any fall, a licensed nurse must immediately assess the resident, notify the physician and family, complete an incident report, and update the care plan. However, in this case, there was no documentation of an assessment, physician or family notification, or follow-up care and monitoring after the resident was found on the floor mattress. Interviews with staff confirmed that the incident was not recognized as a fall by the LVN who was informed, and therefore the required procedures were not initiated. The DON acknowledged that being found on the floor mattress should be considered a fall and that the fall policy should have been followed. The resident's medical record did not contain evidence of assessment or notification, and the DON was unaware of the incident until it was brought up during the survey. This failure to follow established protocols had the potential to negatively impact the resident's well-being.