Failure to Document and Respond to Resident Fall Resulting in Serious Injury
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with a history of falls and severe cognitive impairment from avoidable falls and related serious injuries. The resident was admitted with vascular dementia, muscle weakness, and a need for assistance with personal care. Despite being identified as high risk for falls, the facility did not consistently document, report, or follow up on the resident's fall that occurred in the resident's room. There was no evaluation or documentation of the fall in the clinical record, and the physician and DON were not notified for a post-fall assessment. No fall investigation or root cause analysis was conducted, and no corrective actions were implemented to prevent further incidents. The clinical record lacked documentation of the fall, physician notification, post-fall assessment, and individualized interventions to prevent further falls. Although a neurological evaluation was completed, it did not lead to appropriate follow-up, and an X-ray order was entered but not completed or tracked. Therapy staff noted the resident's pain and attempted to notify the physician and Director of Rehab, but there was no documentation that nursing staff were informed. The resident's pain was not adequately documented or managed, and the resident was later transferred to the hospital for altered mental status, where a right femoral fracture and lumbar vertebrae fracture were identified. Interviews with facility staff revealed a lack of awareness and breakdowns in protocol regarding the fall, with the DON and Unit Manager unaware of the incident and the X-ray order. The facility did not have a system in place to identify residents at risk for falls or to ensure that incidents were reported and followed up appropriately. The incident was not included in the facility's fall report, and the attending physician was not notified of the fall or the resident's pain. The failure to document and respond to the fall resulted in a delay in identifying serious injuries.