Failure to Prevent Accident and Ensure Timely Reporting After Resident Fall
Penalty
Summary
A deficiency occurred when a Certified Nurse Assistant (CNA) left a resident unattended and positioned on their side on a low air loss mattress, resulting in the resident falling out of bed onto a fall mat. The CNA had been providing incontinence care, rolled the resident to their side, and then left the room to care for other residents. Upon returning, the CNA found the resident on the floor. The bed was not in the lowest position at the time of the incident. The resident was totally dependent on staff for all activities of daily living, had quadriplegia, a traumatic brain injury, and a seizure disorder, and was cognitively intact and able to communicate what had happened. The CNA did not immediately report the fall to the charge nurse or any other staff member. Instead, the CNA checked the resident for injuries, used a Hoyer lift to return the resident to bed without assistance, and only later mentioned the incident, with uncertainty about whom it was reported to and when. The lack of immediate notification meant that the resident was not promptly assessed by a nurse for injuries, and the Primary Care Physician (PCP), responsible party, and Interdisciplinary Team (IDT) were not notified in a timely manner as required by facility policy. Facility policy required that all accidents or incidents be promptly investigated and reported, with the nurse supervisor or charge nurse completing an incident report and notifying appropriate parties within 24 hours. In this case, the policy was not followed, as the fall was not immediately reported, and the required assessments and notifications were delayed. The resident later complained of neck pain and was eventually sent to the hospital for evaluation, where a head injury was diagnosed. Interviews confirmed that the CNA was unaware of the requirement to provide care in pairs for this resident and did not know to report falls immediately.