Failure to Document Nursing Fall Assessment After Resident Fall and Injury
Penalty
Summary
A resident with diagnoses including Parkinson's Disease and muscle weakness, and who had severely impaired cognition and required partial to moderate assistance with activities of daily living, experienced an unwitnessed fall in his room resulting in a cut to his left eyebrow. The resident's physician was notified, and staff were instructed to monitor the resident and conduct neuro checks following the incident. Upon review of the resident's medical record, there was no documented evidence that a Nursing Fall Assessment was completed after the fall and injury. The Director of Nursing confirmed that a licensed nurse should have completed a Nursing Fall Assessment to guide staff in implementing appropriate interventions. The facility's policy indicated that staff are to identify interventions related to the resident's specific risks and causes to prevent falls and minimize complications, but this was not documented in this case.