Failure to Properly Assess and Intervene After Unwitnessed Fall with Suspected Head and Neck Injury
Penalty
Summary
A resident with severe cognitive impairment, dependent for transfers, and multiple diagnoses including dementia, diabetes, and atrial fibrillation, experienced an unwitnessed fall in the dining room. The resident was found lying face down, bleeding, and in significant pain, with limited ability to move her extremities and unable to move her head. Staff on duty, including a registered nurse and certified nursing assistants, attempted to roll the resident onto her back multiple times but were unsuccessful due to the resident's pain and position. Emergency Medical Services were called, and upon arrival, EMS and staff turned the resident onto her back and transported her to the emergency room, where multiple fractures were diagnosed, including an odontoid fracture, head injury, nasal fracture, and cervical fractures. Staff interviews revealed that the nurse assessed the resident for movement and pain but did not suspect a neck fracture at the time. Despite the presence of blood and the resident's inability to move her head or extremities fully, staff attempted to move the resident before EMS arrived. Facility policy directed staff to evaluate for possible injuries to the head, neck, spine, and extremities after a fall and to provide appropriate first aid or obtain medical treatment immediately if there was evidence of injury. The policy and staff interviews indicated that residents with suspected head or spinal injuries should not be moved and should be sent directly for medical evaluation. The deficiency occurred because staff did not accurately assess the potential for spinal injury and attempted to move the resident despite clear signs of possible head and neck trauma. The actions taken were inconsistent with facility policy and best practices for managing unwitnessed falls with suspected injuries, as confirmed by staff and administrative interviews. The incident highlights a failure to provide appropriate interventions following a significant fall event.