Failure to Promptly Identify and Intervene After Resident Falls
Penalty
Summary
The facility failed to promptly identify and intervene for changes in condition following falls for two residents with severe cognitive impairment. In the first case, a resident with a history of multiple falls, severe cognitive impairment, and significant neurological diagnoses experienced a witnessed fall in which staff observed the resident hit her head. Despite multiple staff noting changes in the resident's behavior—including increased sleepiness, bulging eyes, and altered responsiveness—there was no documentation of provider notification regarding these changes. The resident was later taken to the hospital by family, where a brain bleed was diagnosed, and subsequently passed away due to complications from blunt force trauma to the head. In the second case, another resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls over a short period. Staff documented initial assessments and follow-up checks, but over the next days, the resident developed increasing pain, bruising, and difficulty bearing weight. Multiple CNAs reported the resident's pain and functional decline to nursing staff, but there was a delay in further assessment and provider notification. Only after significant pain and inability to bear weight were observed did the facility obtain an x-ray, which revealed a hip fracture requiring surgical intervention. Both cases demonstrate failures in timely recognition and escalation of significant changes in condition following falls, despite staff observations and facility policies requiring provider notification for such events. Documentation gaps and communication breakdowns between CNAs, nurses, and providers contributed to delays in appropriate assessment and intervention for these residents.