Failure to Assess and Document Injuries After Multiple Falls
Penalty
Summary
The facility failed to provide timely and accurate assessment and interventions for a resident with a history of multiple falls and significant cognitive impairment. Despite documented care plans requiring weekly treatment documentation and detailed skin assessments, staff did not consistently complete or document skin assessments, measurements, or descriptions of injuries following several falls. There was also a lack of documentation regarding notification of the physician and family after incidents resulting in visible injuries, such as abrasions, swelling, and bruising. The resident, who was admitted for respite care and had diagnoses including cancer, anemia, deep venous thrombosis, benign prostatic hyperplasia, and dementia, experienced multiple falls during the stay. On several occasions, the resident was found on the floor with injuries such as abrasions, skin tears, and swelling, but the clinical record lacked comprehensive skin assessments, wound measurements, and timely documentation of these injuries. Additionally, there was insufficient evidence that the physician or family was notified after these incidents, despite the care plan and facility policy requiring such actions. Family interviews revealed concerns about the lack of communication regarding the resident's injuries, particularly a swollen and bruised hand that was later found to have fractures upon transfer to another facility. Staff interviews indicated that assessments and follow-up actions were not consistently performed or documented, and there was confusion among staff regarding the need for further medical evaluation. Facility policy required follow-up assessments and physician notification for changes in resident condition, but these procedures were not followed in this case.