Failure to Ensure Staff Competency in Fall Assessment and Pain Management
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated the necessary competencies and skill sets to provide safe and appropriate care for residents, as evidenced by the handling of a new admission who experienced an assisted fall. The resident, who had significant medical conditions including metabolic encephalopathy, type 2 diabetes, cirrhosis of the liver, and sepsis, was admitted and within hours experienced a fall during toileting assistance. Nurse aides assisted the resident to the floor and subsequently moved her without a nurse first assessing for pain or injury, contrary to facility protocol and policy. The nurse on duty was informed of the incident but did not perform an assessment before the resident was moved, and the resident later complained of significant pain in her left leg. Communication failures were evident among staff. Nurse aides did not promptly relay the resident's complaint of pain to the appropriate nurse, and the nurse did not provide the oncoming nurse with information about the fall during shift change. As a result, the resident's pain was not fully assessed before pain medication was administered, and the incident was not properly communicated or documented in a timely manner. Multiple staff interviews confirmed that the protocol requiring a nurse to assess any resident after a fall before movement was not followed, and that there was confusion or lack of clarity about the incident among both nurse aides and licensed nurses. Record reviews and staff interviews further revealed that the facility's policy required a thorough nursing assessment after any fall, including vital signs, musculoskeletal evaluation, and pain assessment, none of which were completed prior to moving the resident. The resident was eventually sent to the emergency room, where a femoral fracture was diagnosed. The deficiency was identified as Immediate Jeopardy due to the failure to protect residents by ensuring staff competency in essential care skills, particularly in the assessment and management of falls and pain.