Failure to Follow Fall Assessment and Notification Protocol After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with vascular dementia, adult failure to thrive, diabetes mellitus, and anemia was found on the floor after an unwitnessed fall. Facility policy requires that a licensed nurse assess any injuries before moving the resident, notify the supervisor and physician, complete a physical assessment, initiate neurological checks, and perform fall, skin, and pain assessments. However, the nurse who found the resident did not assess the resident prior to moving them, did not notify the physician, and did not initiate neurological checks or complete a new fall risk assessment as required by policy. The nurse also relied on assistance from CNAs to move the resident before conducting an assessment. Documentation in the medical record did not support that the required notifications and assessments were completed. The nurse supervisor and DON were unaware of the incident until after it occurred and confirmed that the facility's protocol was not followed. The failure to follow established procedures for assessment and notification after an unwitnessed fall resulted in the resident not receiving care and treatment that met professional standards of nursing practice.