Failure to Monitor and Communicate After Resident Fall with Head Injury
Penalty
Summary
Facility staff failed to protect a resident from neglect following an unwitnessed fall that resulted in a head injury. The resident, who had severe cognitive impairment and was on the anticoagulant Eliquis, was identified as having a cut on the right side of his head after the fall. Despite the presence of a head injury and the resident's high risk for bleeding due to anticoagulant therapy, staff did not communicate the injury to the nurse in a timely manner, nor did they initiate neurological assessments as required by facility policy. Multiple staff members observed the injury and noted changes in the resident's behavior, such as increased lethargy, but did not report these findings or escalate care appropriately. The nurse who eventually assessed the resident performed only a single neurological check and, despite being aware of the resident's anticoagulant use, did not initiate ongoing neuro checks or communicate the incident to other staff or the physician as required. The incident report was completed as a late entry, and there was no documentation of physician notification or of the resident's change in condition. Facility policies required neuro checks for 72 hours after any unwitnessed fall or head injury, especially for residents on anticoagulants, but these protocols were not followed. The resident's condition deteriorated over the following days, with staff and family members observing increased lethargy and a lack of normal behavior. The resident was eventually found unresponsive with blood around the mouth and was sent to the hospital, where a large subdural hematoma was diagnosed. The resident subsequently passed away due to a nonsurvivable head bleed. Interviews with staff and review of records confirmed that required assessments, monitoring, and communication were not performed according to policy, resulting in neglect.
Removal Plan
- The facility RN B was suspended immediately pending investigation by the administrator.
- All current staff were in-serviced on abuse and neglect and reporting abuse or neglect policy and procedures by the Director of Nursing. For those who cannot be reached by phone will not return to work without receiving this in-service. Staff will be questioned, 3 random staff members, three times a week for 4 weeks to ensure comprehension.
- The director of nursing was educated on the neurological policy by the VP of Clinical Services. The Director of Nurses was educated by the VP of Clinical Operations, related to the policy stating that neuro checks will be initiated upon any unwitnessed fall or fall with head injury, to continue unless otherwise indicated.
- All current nursing staff were in-serviced on documentation of Unwitnessed falls and Neuro Check Policy by the Director of Nursing. For those who cannot be reached by phone, will not return to work without receiving this in-service. Staff will be questioned, 3 random staff members, three times a week for 4 weeks to ensure comprehension.
- RN B will complete all in-services 1:1 with the DON if allowed to return work with residents.
- The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect is completed by all staff members. Completion will be reviewed at monthly QAPI meetings.
- DON is responsible for ensuring that all assigned nursing in-service are completed. For those who cannot be reached by phone, will not return to work without receiving this in-service prior to anyone working. The administrator will review any new staff to ensure in-services are completed, prior to their first shift on the floor.
- DON reviewed all other residents on anticoagulants for falls and neuro check documentation. No further injuries were noted on any residents.
- Social worker completed Safe Surveys on the other interviewable residents to ensure they feel safe and free from abuse and neglect. No residents reported signs of Abuse or Neglect.
- Any staff member suspected of committing abuse/neglect will be suspended immediately and/or terminated depending on the outcome of the investigation.
- Staff who fail to report suspected abuse and change in condition will be educated on the significance of reporting time and disciplined accordingly.
- DON/Designee will conduct random questioning on 3 staff members daily for 4 weeks for staff to ensure they are understanding and retaining the education on abuse and neglect and reporting procedures.
- Results from random staff questioning will be reviewed during the monthly QAPI meetings with DON, Administrator, and Medical Director. Any incorrect answers will be corrected immediately. Progress will also be monitored during weekly Committee Meetings and Medical Director will be notified of all progress.