Failure to Monitor Resident After Fall Incident
Penalty
Summary
The facility failed to provide necessary care and services to ensure a resident attained and maintained their highest practicable well-being following a witnessed fall. The resident, who had severe cognitive impairment and required substantial to maximal assistance with mobility, experienced a fall when being wheeled by a CNA; the wheelchair became stuck in a carpet, causing the resident to slide forward. Although the resident did not hit their head or sustain injuries, the facility's policy required that after any fall, the resident should be assessed and monitored for pain, discomfort, vital signs, and changes in level of consciousness, with documentation of all assessments and actions. Despite these requirements, there was no documented evidence that licensed nurses continued to monitor or assess the resident after the fall incident. Both the RN and DON confirmed that the resident was not monitored every shift for 72 hours as required by facility policy following a change in condition such as a fall. The lack of continued monitoring and assessment was verified through medical record review and staff interviews, indicating a failure to follow established protocols for post-fall care.