Failure to Assess and Monitor Resident After Fall with Injury
Penalty
Summary
The facility failed to monitor and assess a resident for a change in condition following a fall with injury. According to the facility's policy, staff are required to promptly notify the resident, physician, and representative of changes in condition, make detailed observations, and document relevant information in the medical record. However, after a resident experienced a fall resulting in a head laceration and ongoing complaints of severe back pain, staff did not complete or document assessments related to the resident's pain, increased confusion, or behavioral changes. The resident continued to report significant pain and exhibited increased confusion and behavioral issues over several days following the fall. The resident, who had a history of cancer, dementia, and other significant diagnoses, required extensive assistance with activities of daily living and had previously experienced falls. Despite ongoing symptoms such as severe pain, confusion, and behavioral changes, there was no evidence of thorough assessment or timely intervention. Four days after the fall, the resident was found lethargic with unresponsive pupils and a large bruise on the head, leading to transfer to the emergency room and subsequent diagnosis of a brain bleed. The Director of Nursing confirmed that no assessments were completed or documented regarding the resident's post-fall symptoms.