Failure to Complete Post-Fall Assessments After Resident's Return from Hospital
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following a change in condition. The resident, who had multiple diagnoses including multiple sclerosis, dementia, muscle weakness, and cognitive communication deficit, experienced a fall from bed and was sent to the hospital for evaluation. Upon return, the resident had sustained fractures to the left clavicle and left ribs 3-6. According to the facility's Fall Prevention and Management policy, follow-up assessments, including vital sign collection, were required for at least the next three consecutive shifts after a fall. However, nursing assessments were not performed or documented upon the resident's return to the facility. Record review showed that neurological assessments were discontinued per physician order after a CT scan, but pain and respiratory assessments, which should have been completed at least once per shift, were not documented until the following day. Interviews with facility staff, including the RN/UM and DON, confirmed that these required assessments were not completed as per policy. The lack of timely and documented assessments following the resident's return from the hospital with significant injuries constituted a failure to provide care in accordance with professional standards.