Failure to Prevent and Respond to Resident Fall Results in Serious Injury
Penalty
Summary
A resident with a history of dementia, Parkinsonism, osteoporosis, traumatic brain injury, and severe cognitive impairment was identified as high risk for falls, with documented balance problems and poor safety awareness. Despite these risks, the resident was left unsupervised after being observed by a CNA leaning over and reaching for the floor while seated. The CNA did not assist the resident to a safe position or ensure her safety before leaving, and subsequently, the resident was found on the floor by a housekeeper, with no staff present in the hallway or at the nurse's station. After the fall, staff failed to perform a post-fall assessment or take vital signs, and the resident's care plan did not include specific interventions for unwitnessed falls. The nurse and CNA lifted the resident from the floor without assessing for injury, despite the resident expressing pain and being unable to bear weight. The nurse did not notify the physician or the resident's responsible party at the time of the incident and delayed communication until the end of the shift. The Director of Nursing later acknowledged that the facility's post-fall policy was not followed and that the incident should have been treated as a fall, regardless of the care plan's note about the resident sitting on the floor. As a result of the fall, the resident sustained a displaced left hip fracture, requiring hospital admission and surgery. Following the injury, the resident experienced significant pain, a decline in physical, social, and mental well-being, and became completely dependent on staff for assistance. The failure to provide adequate supervision, timely assessment, and appropriate post-fall interventions directly contributed to the severity of the resident's injury and subsequent decline.