Failure to Assess and Respond to Resident Fall Resulting in Delayed Treatment
Penalty
Summary
A resident with multiple medical conditions, including dementia, muscle weakness, osteoarthritis, and a history of falls, experienced an unwitnessed fall in their room. The resident's roommate reported hearing a loud noise and the resident expressing pain, after which she activated the call light and called for staff assistance. Staff response was delayed, and when they arrived, the resident was assisted back to bed without a documented assessment or evaluation for injuries as required by facility protocol. No documentation of the fall or post-fall assessment was found in the medical record for the date of the incident. Over the following days, the resident continued to complain of hip pain, which was reported by the roommate to staff on multiple occasions. It was not until two days after the fall that staff documented the resident's complaints and ordered an X-ray, which revealed a right hip fracture. The resident was subsequently transferred to a hospital for surgical intervention. The facility's own investigation confirmed that the assigned nurse failed to perform or document a post-fall assessment, did not notify supervisory staff, the physician, or the resident's family, and did not follow established protocols for managing unwitnessed falls and changes in condition. Facility policies required a full post-fall assessment, including neurological checks and range of motion evaluation, before moving a resident after a fall, as well as timely notification of the physician, family, and supervisory staff in the event of a significant change in condition. These procedures were not followed in this case, resulting in a delay in identifying and treating the resident's injury. The deficiency was substantiated through interviews, record reviews, and policy comparisons, which demonstrated a failure to protect the resident from neglect and to ensure their right to be free from abuse and neglect.