Failure to Follow Post-Fall Protocol and Notification Procedures
Penalty
Summary
A resident experienced a fall from bed during the early morning hours, which was witnessed by the roommate. The roommate alerted a CNA, who then notified an LPN. The LPN arrived with another CNA, questioned the resident, and returned the resident to bed without performing an assessment. The LPN failed to document the fall in the medical record, did not initiate neurological checks, did not complete a Post Fall Evaluation form, and did not notify the resident's primary care physician or the resident's representative as required by facility policy. Additionally, the LPN did not communicate the incident to the oncoming RN during shift change. Later that day, the resident reported nausea and headache to the RN, who was then informed by the roommate about the earlier fall. The RN notified the APRN, who ordered medication and assessed the resident, ultimately directing a transfer to the hospital where the resident was diagnosed with a head injury/concussion. Facility leadership confirmed through their investigation that the LPN did not follow post-fall protocols, failed to document the incident, and did not notify appropriate parties as required.