Failure to Document and Respond to Unwitnessed Fall
Penalty
Summary
The facility failed to follow appropriate procedures after an unwitnessed fall involving a resident with multiple medical conditions, including orthopedic aftercare, lower leg fracture, abnormal gait, diabetes, hyperlipidemia, kidney disease, hypertension, and syncope. The resident reported that call lights were not answered for extended periods, leading him to attempt to get up unassisted during the night, resulting in a fall. A nurse discovered the resident after the fall, but there was no documentation of the incident, no notification to the physician, and no evidence of post-fall monitoring or change of condition assessment. Interviews with nursing staff and review of the resident's records confirmed that the fall was not documented in the progress notes, and required notifications and monitoring were not completed. The Director of Nursing and other staff acknowledged that facility policy required documentation, physician notification, and monitoring after such incidents, but these actions were not taken. The facility was unable to provide any documentation that the required procedures were followed after the resident's fall.