Failure to Report and Respond to Unwitnessed Fall Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not properly reporting, assessing, documenting, or intervening in a timely manner after an unwitnessed fall that resulted in a major injury. The resident, who had severe cognitive impairment and multiple comorbidities including dementia, coronary artery disease, and was under hospice care, was found on the floor by a CNA. The CNA notified a nurse, who assessed the resident and, along with two other staff, assisted the resident into a wheelchair. The nurse did not report the incident as a fall, did not notify the physician or the DON, and did not document the event as required by facility policy. The nurse assumed the resident's behavior was typical and did not consider the possibility of injury, despite the resident being combative and having a skin tear. Following the incident, the resident was observed by staff and family, with the family later reporting the resident was in pain during a transfer. The pain was communicated to the nurse, but no immediate action was taken to further assess or report the change in condition. It was only after the family informed the hospice nurse of the fall and the resident's pain that a stat X-ray was ordered, which revealed an acute right hip fracture. The resident subsequently received pain management and comfort care, but the delay in assessment and intervention resulted in ongoing pain and suffering until the resident's death. Interviews with facility staff, including the DON, RN, CNA, hospice nurse, and family members, confirmed that the incident was not reported or investigated in accordance with facility policy. The nurse involved did not recognize the event as a reportable fall and failed to notify appropriate parties or document the occurrence. The facility's policies required immediate reporting, assessment, and documentation of any accident or change in condition, which were not followed in this case. This failure led to a determination of Immediate Jeopardy due to the worsened condition and likelihood of serious injury or death for the resident.