Failure to Document, Assess, and Report Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and high fall risk was found on the floor in his room. The licensed nurse on duty failed to document the fall, did not assess the resident for injuries such as fractures, and did not notify the DON or physician. The clinical record lacked evidence of a fall investigation or implementation of interventions to prevent further incidents. The resident's care plan required substantial to maximal assistance with activities of daily living, including transfers, and the resident was not ambulatory due to medical and safety concerns. Following the fall, the physical therapy assistant documented that the resident verbalized right knee and groin/hip pain but did not communicate this change in condition to the nursing department. A unit manager later wrote an order for an X-ray of the right hip, but the X-ray was never performed, and a nurse incorrectly marked it as completed. There was no documentation of the X-ray results, and the resident's pain was not properly evaluated or reported. The resident continued to decline, requiring maximum assistance for mobility, and was eventually transferred to the hospital for altered mental status and abnormal labs. Hospital imaging revealed a comminuted intertrochanteric right femoral fracture and an acute lumbar vertebra fracture. Interviews with facility staff revealed a lack of awareness and communication regarding the fall, the X-ray order, and the resident's change in condition. The DON and unit manager were not notified of the fall, and there was no formal system to track diagnostic orders or ensure follow-up. The physical therapy and nursing documentation systems were not integrated, leading to missed communication about the resident's pain. The facility's policies required assessment, documentation, and reporting of falls and changes in condition, but these processes were not followed, resulting in neglect and a determination of Immediate Jeopardy.