Failure to Ensure RN Assessment and Adequate Monitoring After Resident Falls
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans. Specifically, two residents who experienced falls were not assessed by a registered nurse (RN) following their incidents, and in one case, a resident on anticoagulant medication did not receive consistent and increased monitoring after sustaining a head injury. The records showed that after a fall, a licensed practical nurse (LPN) performed the initial assessment, but there was no documentation of RN involvement or consultation, despite facility policy and professional standards requiring RN assessment, especially in cases involving head injuries or anticoagulant use. One resident, with a history of atrial fibrillation, muscle weakness, and difficulty walking, was taking Eliquis, an anticoagulant. After an unwitnessed fall where she hit her head, the resident was evaluated by an LPN, who found no injuries. However, the resident began complaining of headache and neck pain later that morning. Despite these symptoms and her anticoagulant use, the facility did not send her to the emergency department for further evaluation and did not increase monitoring beyond the standard neurological assessment protocol. Neurological assessments were not completed consistently as scheduled, and three days after the fall, the resident was transported to the hospital, where a significant subdural hemorrhage was diagnosed. Another resident, with severe cognitive impairment and a history of falls, was found on the floor with a head laceration and a large skin tear after a fall. The LPN on duty performed the assessment and assisted the resident from the floor before EMS was called. There was no documentation that an RN assessed the resident prior to her being moved. Staff interviews confirmed that facility policy required RN assessment after falls, particularly for residents on blood thinners or with head injuries, but at the time of both incidents, no RN was present in the building, and no RN assessment was documented.