Failure to Ensure Nursing Assessment Before Moving Resident After Fall
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living and required two or more staff for mechanical lift transfers, was not properly assessed and evaluated by a nurse before being moved after a fall. The facility's policy required that accident victims not be moved until examined by a nurse, but this protocol was not followed. Instead, after the resident fell during a mechanical lift transfer performed by a single certified nursing assistant (CNA) without the required second staff member, the resident was assisted from the floor back to bed by two CNAs without prior nursing assessment. The incident began when a CNA attempted to transfer the resident alone using a mechanical lift, contrary to the resident's care plan and facility policy, which mandated two staff for such transfers. The CNA reported being unable to find assistance and proceeded alone, resulting in the resident falling to the floor. Another CNA entered the room, observed the resident on the floor, and helped move the resident back to bed before notifying the charge nurse. Both CNAs involved did not follow the protocol to summon help or ensure a nurse assessed the resident prior to moving them. Interviews confirmed that the nurse manager and LPN were not informed of the incident until after the resident had been placed back in bed. Upon assessment, the resident exhibited decreased passive range of motion and pain in the right lower extremity, and subsequent investigation revealed a right hip fracture requiring surgical intervention. The facility's investigation concluded that the care plan and accident protocol were not followed, and there was no documentation of a nursing assessment prior to moving the resident after the fall.