Failure to Monitor and Assess Resident After Fall
Penalty
Summary
Nursing staff failed to ensure appropriate monitoring and assessment of a resident following a fall, as required by the facility's clinical protocol. After being found on the floor by an LPN, the resident, who had significant cognitive impairment and a history of vertebral fractures, was examined and reported pain in the left wrist and arm. The physician was notified and ordered extra strength Tylenol, and an x-ray was performed. However, there was no documentation that the ordered Tylenol was administered, nor was there evidence of continued monitoring or assessment for injuries, pain, or changes in condition after the fall. The resident was later transferred to a hospital emergency room for a psychiatric evaluation, where additional injuries, including a black and blue bruise to the coccyx area and pain upon turning, were noted. Hospital staff reported that the only information received from the transferring facility was that the resident had fallen two days prior and had wrist pain, with an x-ray performed. The Assistant Director of Nursing confirmed that there was no documentation of ongoing monitoring or assessment after the fall, as required by facility policy.