Failure to Assess and Document Care Following Resident Fall
Penalty
Summary
The facility failed to properly assess and intervene following a fall for one resident. After the resident experienced a fall, staff did not complete an Incident Report as required by facility policy, and there was a lack of documentation regarding the presence of an abrasion on the resident's right knee. Nursing staff did not perform neurological assessments according to protocol, which required checks every 15 minutes for the first three intervals, then every four hours, and then every eight hours. Additionally, there was no documentation of treatment provided to the resident's knees, despite the presence of a bandage with sanguineous drainage and an open area the size of a half-dollar noted on the right knee. Staff interviews revealed confusion and lack of communication regarding the fall, the resident's injuries, and the required interventions. The nurse on duty at the time of the fall was new and had not previously managed a fall incident, contributing to the failure to complete necessary documentation and assessments. The facility's risk management policy required neurological assessments for unwitnessed falls or possible head injuries and completion of Incident Reports by the end of the nurse's shift, both of which were not followed in this case.