Failure to Assess and Document After Resident Fall Resulting in Fracture
Penalty
Summary
A resident with severe cognitive impairment and a history of frequent falls was not properly assessed after an incident in which she slid out of a recliner. Staff assisted her back to the chair and later to a wheelchair, noting that she was rubbing her thighs and was given Tylenol for discomfort. No signs or symptoms of pain or discomfort were documented at the time of the incident, and the resident was able to eat supper with a good appetite. However, there was no assessment conducted at the time of the fall, and no incident report or nursing note was completed immediately following the event. The following day, the resident began complaining of left hip pain, which led to an x-ray being ordered and a left hip fracture being identified. The resident was subsequently sent to the hospital for surgical repair. The facility's failure to assess the resident after the fall and to complete the required incident report and documentation resulted in a delay in identifying the injury and providing appropriate medical intervention.