Failure to Follow Post-Fall Assessment Policy
Penalty
Summary
A deficiency occurred when a resident with diagnoses of depression and muscle wasting, and identified as being at risk for falls, did not receive care in accordance with the facility's post-fall assessment policy. After an unwitnessed fall in her room, surveillance video showed that an LVN entered, briefly checked on the resident, and then supervised her movement from the floor to her bed without first performing vital signs or neurological status checks. The resident's care plan included multiple fall prevention interventions, but the required post-fall assessment was not completed prior to moving her. Interviews with the ADON, LVN, and DON confirmed that the facility's policy requires a licensed nurse to evaluate a resident's condition, including vital signs and neurological status, before moving them after a fall. The LVN involved acknowledged not following this protocol and stated the importance of such assessments to prevent further harm. The facility's policy, last revised in 2014, specifically directs that residents should not be moved until this evaluation is completed, unless absolutely necessary. This protocol was not followed in the incident involving the resident.