Failure to Follow Post-Fall Assessment Protocol Before Moving Resident
Penalty
Summary
The facility failed to ensure that staff members acted competently and followed established protocol regarding the notification and assessment by a licensed nurse after a resident experienced a fall. Specifically, a certified nurse aide (CNA) and the Respiratory Manager moved a resident who had fallen during a transfer using a Hoyer lift, without first notifying or obtaining an assessment from a nurse as required by facility policy. The CNA reported that the resident fell out of the Hoyer pad during a transfer, and the Respiratory Manager assisted in repositioning the resident and transferring him back to bed before a nurse was notified. When the nurse was eventually informed, the resident had already been moved and was back in bed. The resident involved had significant medical conditions, including chronic respiratory failure with ventilator dependence, a G-tube, cerebral palsy, paraplegia, and an anxiety disorder. After the fall, a hematoma was observed above the resident's left eyebrow. Facility policy required that any resident experiencing a fall be immediately assessed by the charge nurse for possible injuries before being moved, but this protocol was not followed in this incident.