Failure to Supervise and Assess Cognitively Impaired Resident After Fall
Penalty
Summary
The facility failed to provide adequate supervision and monitoring for a cognitively impaired resident with a history of wandering, resulting in an unwitnessed fall that caused a major injury. The resident, who had Alzheimer's disease and was nonverbal, was found on the floor in the dining room by staff after the fall. Staff manually lifted the resident from the floor to a wheelchair and then to bed, despite the resident showing signs of pain and having a visible hematoma on her head. The nurse on duty did not perform a thorough assessment of the resident's lower extremities and did not complete a pain assessment or document the incident properly in the medical record. Communication among staff was incomplete and inconsistent. The night shift nurse did not immediately communicate all symptoms, including the resident's hip pain, to the DON, which delayed the decision to send the resident to the hospital. The resident remained in the facility overnight, and only after the day shift nurse assessed her condition and noted significant pain and a deformity of the hip was EMS called and the resident transferred to the hospital. The delay in transfer resulted in the resident requiring hospitalization and surgery for a hip fracture, and she lost her ability to ambulate independently. The facility's policies and procedures for fall prevention, post-fall assessment, and notification of changes were not followed. Required documentation, such as a complete neurological assessment and pain evaluation, was missing or incomplete. The care plan for the resident, which identified her as a high fall risk due to wandering and cognitive impairment, was not adequately implemented to prevent the accident or ensure timely and appropriate response after the fall.