Failure to Complete Thorough Post-Fall Assessments and Monitoring
Penalty
Summary
A resident with severe cognitive impairment, dementia, and anxiety, who required substantial assistance for transfers and toileting, experienced multiple unwitnessed falls over a period of several weeks. The resident's care plan identified a high risk for falls and included various interventions, such as increased rounding at night, use of non-skid footwear, and ensuring assistive devices were appropriately placed. Despite these interventions, the resident continued to fall, and documentation revealed repeated bruising and injuries, including a hematoma and bulge on the back of the head, as well as pain and behavioral changes following the falls. Post-fall assessments and monitoring were not thoroughly completed after each incident. Neurological checks were documented as normal, and there was no documentation of weakness or unusual movement of the resident's limbs in the 72 hours following each fall. Several injuries, including bruises and a hematoma, were not promptly identified or reported. Communication with the resident's family was inconsistent, with the family often being notified of falls days after they occurred or not at all. When the resident developed severe pain and visible injuries, the family had to insist on hospital transfer, where multiple acute fractures were discovered. Interviews with staff indicated that falls were sometimes not documented, and that the resident's pain and injuries were not always fully assessed or communicated to providers or family members. The Director of Nursing and Clinical Care Coordinator were aware of the resident's repeated falls and subsequent injuries but did not report all findings to the provider or family. The lack of thorough post-fall assessment, inadequate monitoring, and poor communication resulted in a delay in identifying serious injuries, including rib, pelvic, and sacral fractures.