Failure to Ensure RN Assessment Before Moving Resident After Fall
Penalty
Summary
A deficiency occurred when a resident with dementia, impaired mobility, and a history of falls experienced a witnessed fall resulting in significant injuries, including a contusion to the forehead, a bruise to the arm, and pain in the ankle. The resident was being assisted by a nursing assistant who did not ensure proper positioning in the wheelchair and moved the resident too quickly, despite the resident's verbal request to stop. The resident subsequently fell forward out of the wheelchair, hitting their head and sustaining further injuries. The incident was witnessed by the resident's roommate, who confirmed that the nursing assistant did not respond to the resident's request to stop and attempted to move the resident after the fall without using the call bell or seeking immediate staff assistance. Following the fall, staff, including the nursing assistant and other personnel, moved the resident from the floor to a sitting position, then assisted the resident into the wheelchair and subsequently into bed before an RN assessment was completed. Interviews and documentation revealed that the resident was in pain and had visible injuries, and that staff did not keep the resident immobile as required by facility policy until a registered nurse could assess for possible fractures or other injuries. The facility's policies directed that after a fall, the resident should remain immobile until examined and cleared by a licensed nurse, and that a thorough evaluation and documentation should be completed. The investigation found inconsistencies in staff accounts regarding whether the resident was moved prior to assessment, with statements from the roommate and staff indicating that the resident was moved multiple times before EMS arrived. The Director of Nursing was unaware that the resident had been moved and did not interview all witnesses. The failure to ensure the resident was assessed by an RN prior to being moved after a fall with major injury constituted a breach of professional standards and facility policy.