Failure to Perform Post-Fall Assessment and Documentation
Penalty
Summary
Facility staff failed to perform a thorough head-to-toe assessment, pain assessment, or appropriate transfer for a resident following an unwitnessed fall with injury. After being notified of the fall, staff members found the resident lying on the floor in the dining room. The staff picked up the resident and placed her in a wheelchair without using a mechanical lift, despite the resident being non-verbal, cognitively impaired, and later showing signs of pain. The staff then transferred the resident to bed, where she exhibited further signs of pain when her clothing was removed. Staff communicated concerns to each other, but the nurse on duty did not complete a full assessment of the resident's lower extremities, did not document a pain assessment, and did not properly document the incident in the medical record at the time of the event. Review of the resident's records showed no documentation of a pain assessment or fall assessment following the incident, and a late entry note was made 140 days after the fall. Facility policies required comprehensive assessments and care in accordance with professional standards, including assessment after any fall. The failure to follow these protocols resulted in an increase in the resident's signs and symptoms of pain due to a hip fracture sustained during the fall.