Failure to Follow Fall Protocols After Resident Fall
Penalty
Summary
The facility failed to ensure that three certified nurse aides (CNAs) followed established fall protocols after a resident experienced a fall. The incident involved a resident with a history of right-sided hemiplegia, osteoarthritis, and altered mental status, who required substantial to maximal assistance for transfers and was at high risk for falls. During a transfer from the toilet to a wheelchair, the resident was not able to sit back fully in the wheelchair, resulting in her knees hitting the wall and her being lowered to the floor by a CNA. The CNA, along with two other CNAs, subsequently assisted the resident from the floor to her bed without waiting for a nurse to assess the resident, despite the resident expressing pain and distress. Documentation revealed that the CNAs did not follow the Indiana State Department of Health Nurse Aide Curriculum, which instructs staff to call for help immediately and keep the resident in the same position until a nurse examines the resident after a fall. Instead, the CNAs moved the resident before a nurse could assess her condition. There were no written statements from two of the CNAs involved, and the facility lacked a specific policy guiding nurse aides on the required actions following a resident fall, aside from referencing the state curriculum. Subsequent medical evaluation found that the resident had sustained an acute, displaced fracture of the femoral metaphysis and a fracture of the metatarsal of the left foot. The resident was treated at a local emergency department and returned to the facility. Interviews confirmed that the CNAs moved the resident due to her complaints of pain and requests to be moved, but did not adhere to the required protocol of waiting for a nurse assessment before moving a resident after a fall.