Failure to Ensure Qualified Assessment After Resident Fall
Penalty
Summary
A deficiency was identified when a resident with a history of falls, chronic obstructive pulmonary disease, hypertension, and anxiety disorder experienced an unwitnessed fall in the evening. The resident was found on the floor by their roommate, and staff documented that vital signs were taken and were stable, with no signs of injury at the time. However, there was no documented evidence that a qualified professional, such as a registered nurse, assessed the resident after the fall, as required by facility policy and professional standards of practice. The facility's Falls Management and Prevention policy required a head-to-toe assessment by a qualified individual following any fall. Documentation from multiple staff members, including certified nurse aides and LPNs, indicated that the resident was checked for safety and vitals were taken, but the assessment by a registered nurse or through telehealth was not completed or documented. Staff interviews revealed that there was no registered nurse in the building during the shift, and although the process was to contact an on-call RN or use telehealth for assessment, this was not done for the resident in question. The resident had a care plan indicating a risk for falls and required assistance with toileting and mobility. Despite these interventions, the resident attempted to toilet independently, resulting in a fall. The lack of a documented assessment by a qualified professional after the incident constituted a failure to provide care in accordance with the resident's care plan and professional standards. The resident expired the following morning, but the report does not link the death directly to the deficiency.