Failure to Monitor and Assess After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with a history of respiratory failure, generalized muscle weakness, and unsteadiness experienced an unwitnessed fall. The resident was found on the floor by a CNA and the Unit Manager, who performed an initial assessment and took vital signs. The Unit Manager instructed the hall nurse to conduct neurological checks, notify the resident's family and physician, and complete the necessary documentation and reporting. However, the hall nurse did not follow up with the resident as directed. The resident later reported that after the fall, no nurse came to assess her or follow up, and her fall was not documented in the facility's list of unwitnessed fall incidents. Interviews with staff revealed a breakdown in communication: the Unit Manager believed she had relayed the necessary information to the hall nurse, while the nurse stated she was not made aware of the fall until days later when the resident herself reported it. As a result, the required post-fall assessments, including neurological checks and notifications, were not completed in accordance with professional standards. The Director of Nursing confirmed that the facility failed to monitor and report the resident's unwitnessed fall, and that the expected protocol—comprehensive assessment, neurological checks, and proper documentation—was not followed. The incident was only brought to the facility's attention after the resident filed a grievance, highlighting the lack of immediate and appropriate follow-up care after the fall.