Resident Moved After Fall Without Prior Nurse Assessment
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, severe cognitive impairment, and dependence on staff for mobility experienced a fall from bed while being cared for by a CNA. After the fall, two CNAs moved the resident from the floor back to bed using a mechanical lift before a licensed nurse could assess the resident for injuries. The RN was only summoned after the resident had already been returned to bed, at which point abrasions were noted on the resident's forehead and knee. Both CNAs involved stated that no assessment was performed prior to moving the resident, and one CNA acknowledged being aware of the protocol but did not follow it due to stress and concern for the resident's immediate care needs. Interviews and record reviews confirmed that the facility's policy required a licensed nurse to assess any resident for injury before being moved after a fall. One CNA reported not being aware of this requirement until after the incident, while the other CNA admitted to prior education on the policy but failed to adhere to it during the event. The facility's training records showed documentation of relevant training for one CNA, but not for the other. The DON and RN confirmed that professional standards and facility policy dictate that a nurse assessment must occur before moving a resident post-fall, regardless of visible injury.