Failure to Follow Professional Standards in Resident Assessment and Post-Fall Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality in two separate incidents involving two residents. In the first incident, a resident with a history of dementia, depression, heart failure, and hypertension, who was at risk for falls, experienced a fall in the dining room. The resident was found on the floor with a head injury, visible deformity of the left wrist, and hip pain. Despite the presence of obvious injuries, including a shortened leg indicative of a hip fracture and a visible wrist deformity, three staff members physically lifted the resident from the floor to a chair before emergency medical services arrived. This action was contrary to the facility's policy, which directs staff not to move a resident with suspected injury until evaluated by a physician or EMS. Interviews with staff and review of facility policy confirmed that the resident should not have been moved, and the Director of Nursing was unable to explain why this occurred. In the second incident, another resident with end stage renal disease, diabetes, hypertension, and a history of stroke-like events, experienced a change in condition characterized by chest pain, hypotension, increased lethargy, mild shortness of breath, and diminished lung sounds. The resident was administered nitroglycerin for chest pain, but subsequent blood pressure readings revealed abnormally low values. Despite these findings, there was no documentation that a Registered Nurse assessed the resident or that the physician was notified of the change in condition. The resident was sent for hemolytic treatment without further assessment or notification to the treatment center regarding the change in condition. Interviews with LPNs and review of the clinical record confirmed that no RN assessment or provider notification occurred during this period. Both incidents demonstrate failures to follow established standards of practice and facility policies regarding the assessment and management of residents with injuries or changes in condition. The deficiencies were identified through observations, record reviews, staff interviews, and review of facility policies, which clearly outlined the required procedures that were not followed in these cases.