Failure to Assess, Document, and Notify After Resident Fall with Injury
Penalty
Summary
Facility staff failed to follow professional standards of practice by not completing an assessment, documentation, or obtaining physician orders for treatment after a resident experienced a fall with injury. The facility's policy requires staff to observe, record, and report any change in a resident's condition, including after a fall, and to notify the physician and responsible party, complete incident reports, and document all assessments and interventions. In this case, there was no documentation of the fall event, no nursing progress notes regarding the fall or treatment of injuries, and no evidence of physician or responsible party notification on the date of the incident. The resident involved had a history of hemiplegia and hemiparesis following a stroke, was confused, verbally communicative, and had unsteady/unsafe independent transfers. The resident's responsible party reported that the resident fell while attempting to use the bathroom independently, sustained a bruise and skin tears, and was treated with butterfly bandages. However, the responsible party was not notified of the fall or injuries, and the facility's records did not reflect any assessment or treatment orders related to the incident at the time it occurred. Interviews with staff revealed that neurological checks were initiated, but the required documentation, notifications, and incident reporting were not completed. Staff members acknowledged that standard procedure was not followed, with each assuming that the necessary steps would be completed by others. The fall event was only documented retroactively after the resident had been discharged and the incident was brought to the attention of facility leadership.