Failure to Ensure Nursing Staff Competency and Oversight After Resident Fall
Penalty
Summary
Nursing staff failed to ensure appropriate assessment, documentation, and follow-up after a resident experienced a fall. The resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, was found on the floor in their room. The nursing staff did not document the fall, notify the physician, or report the incident to the next shift or therapy department, as required by facility policy. There was also no documentation of individualized interventions to prevent further falls or of a thorough evaluation of the incident. Further review revealed that a physician's order for diagnostic X-rays was entered, but the X-rays were never completed, and the results were not documented. Nursing staff incorrectly indicated on the treatment administration record that the X-rays had been done. There was no system in place to track diagnostic orders to ensure completion and communication of results. Additionally, the therapy department was not notified of the fall, and there was a lack of documentation regarding the resident's subsequent pain and decline in mobility. The resident was later transferred to the hospital, where a right femoral fracture and lumbar vertebrae fracture were identified, along with new onset hematuria and a Foley catheter placement without a documented physician order. Interviews with facility staff, including the DON and medical director, confirmed a lack of awareness of the fall, missing documentation, and absence of a system to identify residents at risk for falls. The facility did not have a nursing supervisor for evening or night shifts, and incident reporting was inconsistent. The resident's fall was not included in the facility's incident report log, and staff failed to follow established protocols for post-fall assessment, documentation, and communication.