Failure to Assess and Treat Resident After Unresponsive Event and Fall
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess a resident who was prescribed a daily anticoagulant and had a do not resuscitate order, after she became unresponsive during a shower and subsequently fell, sustaining injuries. The resident, who had diagnoses including a sacral fracture, ascending aorta aneurysm, and lumbar radiculopathy, was sitting on a shower bench when she suddenly went limp and unresponsive. The nursing aide assisting her laid her across the bench and left her unattended to seek help, during which time the resident slid off the bench and hit her face on the floor, resulting in a laceration to her right eyebrow with significant bleeding and a skin tear to her right elbow. Upon arrival, the nurse did not perform a head-to-toe assessment, did not check vital signs, did not assess for pain or range of motion, and did not apply pressure to the bleeding laceration. The nurse only checked for a wrist pulse and did not attempt to cover the resident or address her injuries further. Multiple staff members were present in the shower room but did not assist in turning the resident over or providing basic first aid, such as applying pressure to the wound, before EMS arrived. The resident remained in the same position on the floor until EMS arrived and transported her. Interviews with staff and the medical director confirmed that the expected protocol after a fall included obtaining vital signs, assessing pain, and checking for bleeding or deformities, none of which were performed. The incident report and EMS documentation corroborated that the resident was left unassessed and untreated for her injuries in the minutes following the fall. The failure to provide appropriate assessment and care after the fall constituted the identified deficiency for this resident.