Failure to Report and Assess Resident Fall
Penalty
Summary
Facility staff failed to report a resident fall to a licensed nurse, resulting in the absence of a nursing and neurological assessment before the resident was moved from the floor. A certified nursing assistant (CNA) discovered the resident on the floor by the bed while delivering a meal tray. Unable to locate the licensed nurse, the CNA, with the help of another CNA, picked up the resident and returned them to bed without notifying the nurse on duty. The incident was only discovered when a family member inquired about the fall during a care plan conference the following day. At the time of the incident, there were at least two licensed nurses and a nurse manager present on the unit. Facility policy requires that all accidents and incidents be reported to the charge nurse, and that residents not be moved until examined by a licensed nurse. The failure to follow this policy led to the resident not being assessed for injuries or neurological changes prior to being moved after the fall.