Failure to Follow Protocol After Resident Fall with Head and Spinal Injuries
Penalty
Summary
Staff failed to follow professional standards of care after an unwitnessed fall involving a resident with multiple diagnoses, including heart failure, anxiety, and chronic pain, and a documented risk for falls. The resident, who had moderate cognitive impairment, was found face down on the floor with visible head injuries, including large lumps on the head, a cut near the eye, abrasions, and complaints of wrist pain. Despite these injuries and the potential for spinal involvement, staff, including an RN and nursing assistants, assisted the resident back into bed using a mechanical lift before the arrival of Emergency Medical Services (EMS). Facility documentation and interviews revealed that the RN assessed the resident and, despite recognizing the possibility of head and spinal injuries, directed staff to move the resident to bed to make them comfortable. The EMS run sheet confirmed that the resident had been moved prior to their arrival and subsequently placed in a cervical collar and transferred to the hospital. Hospital records documented multiple traumatic injuries, including a subdural hematoma, subarachnoid hemorrhage, facial fractures, wrist fractures, and a T8 vertebral fracture, with the resident ultimately expiring after admission. Interviews with staff, including the RN, nursing assistants, and the Director of Nursing Services (DNS), indicated uncertainty or lack of knowledge regarding the appropriate response to a resident with suspected head and spinal injuries following a fall. Facility policy directed minimizing injury after a fall, but staff actions did not align with standards for managing potential head and spinal trauma, as the resident was moved prior to EMS assessment.