Failure to Assess and Intervene After Falls and Wound Development
Penalty
Summary
Staff failed to properly assess and intervene for two residents, resulting in deficiencies in care. One resident with significant cognitive impairment, visual deficits, and a history of falls was observed via facility video to have fallen after tripping over her catheter tubing. Staff present did not immediately respond to the fall, and when they did, they moved the resident multiple times without performing a thorough assessment as required by facility policy. The resident complained of severe leg pain, but staff continued to move and ambulate her without using a gait belt or completing a full assessment, including vital signs and range of motion. The resident was later sent to the emergency department, where a femur fracture was diagnosed. Interviews confirmed that staff did not follow the facility's fall policy, which required a nurse to assess the resident on the floor before moving her, and that documentation of the incident was delayed and incomplete. Additionally, the same resident was administered medications intended for another resident, including Melatonin, Mirtazapine, Alprazolam, and Apixaban. The error was not fully reported to the emergency department, as only one of the four medications was disclosed. Staff interviews revealed confusion and lack of adherence to medication administration and error reporting protocols. The Director of Nursing confirmed that the nurse's assessment after the fall was not as thorough as expected and that vital signs were not taken as required. A second resident, with diagnoses including heart failure, diabetes, and dementia, was readmitted with a right trochanter blister. The facility failed to assess the blistered area for two weeks, with no measurements or detailed assessment documented during that period. When the wound was eventually assessed, it had worsened, showing signs of infection and requiring antibiotic treatment. The Director of Nursing confirmed that staff failed to assess the resident's wound as required.