Failure to Ensure Timely Nursing Assessment After Resident Fall
Penalty
Summary
The facility failed to ensure that nursing assessments following a resident fall were conducted in accordance with professional standards and facility policy. Specifically, after a resident experienced a fall in their bathroom, a nursing assistant assisted the resident back into their wheelchair before a licensed nurse assessed the resident for injuries. The progress notes indicated that the resident had pain and swelling to their ankle and required ice and further diagnostics to determine the extent of the injury. According to facility policy, nursing staff are required to complete fall risk assessments and assess the level of injury before moving a resident after a fall. Interviews revealed that the assigned nurse was on a lunch break at the time of the fall, and although another nurse was available in a different hallway, the nursing assistant did not request their assistance and proceeded to move the resident. The Director of Nursing confirmed that the nursing assistant had been employed at the facility for four years and was aware of the policy requiring a nurse to assess a resident before they are moved after a fall. This lapse in following established protocols resulted in the resident being moved prior to a proper nursing assessment.