Resident Left Unattended After Unwitnessed Fall
Penalty
Summary
A resident with multiple diagnoses, including metabolic encephalopathy, osteoarthritis, osteomyelitis, low back pain, muscle weakness, a history of falls, and difficulty walking, experienced an unwitnessed fall. The resident was found on the floor after sliding forward out of a wheelchair while attempting to reach the bathroom. The clinical record indicated the resident was at moderate risk for falls, required extensive assistance with bed mobility and toileting, and was unable to independently stand. Following the fall, the resident complained of bilateral hip and right shoulder pain, and the on-call Advanced Practice Registered Nurse directed that the resident be sent to the Emergency Department for evaluation. Facility documentation and the EMS report revealed that the resident was left alone on the floor in their room while awaiting EMS arrival. The facility did not have a policy in place at the time addressing whether staff should remain with a resident after a fall while waiting for EMS, although the Director of Nursing stated it was the expectation that staff would stay with the resident. The facility's unwitnessed falls policy directed that residents not be moved if a fracture or serious condition was suspected, but did not specify supervision requirements during the wait for EMS.