Failure to Ensure Timely and Documented RN Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that post-fall assessments for several residents were completed timely by a qualified person, specifically a registered nurse (RN), and that these assessments were properly documented in the residents' medical records. In multiple instances, after residents experienced falls—either unwitnessed or witnessed—initial assessments were conducted by licensed practical nurses (LPNs), but there was no documentation of follow-up assessments by an RN as required by facility policy. For example, one resident with hepatic encephalopathy, schizophrenia, and other complex conditions reported an unwitnessed fall and was assessed by an LPN, but there was no record of an RN assessment in the electronic medical record (EMR). Another resident, dependent on staff for all activities of daily living and with diagnoses including encephalopathy and severe vision impairment, experienced a fall while attempting to self-transfer. The director of nursing (DON) stated she assessed the resident after the fall but did not document her assessment until three days later. Similarly, a resident with multiple sclerosis and a history of falls was found on the floor by a CNA and assessed by an LPN, with no documentation of an RN assessment in the EMR. In another case, a resident with neurofibromatosis and muscle weakness slipped off the toilet and was assessed by an LPN, but again, there was no timely RN assessment documented. Staff interviews revealed that RNs sometimes performed assessments but did not document them if their findings matched those of the LPNs, and that documentation was sometimes delayed or omitted entirely. The facility's policy required that all post-fall assessments be completed by an RN and documented in the medical record, but this was not consistently followed, leading to incomplete records and a lack of evidence that qualified personnel provided care according to each resident's plan of care.