Failure to Assess Resident After Reported Change in Mobility and Possible Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to perform a physical assessment of a resident after a change in the resident's ability to self-transfer was reported. The resident, who had a history of dementia, stroke, and legal blindness, was known to require supervision for all mobility tasks and had a care plan focused on fall prevention. On the evening in question, a nurse aide observed the resident having difficulty transferring from a wheelchair to bed and reported that the resident mentioned possible hip pain. Additionally, the resident's roommate reported that the resident had fallen a couple of nights prior. Despite these reports, neither the assigned nurse nor other nurses on duty conducted a physical assessment of the resident at that time. Multiple staff interviews confirmed that the nurse aide communicated the resident's difficulty and the roommate's report of a fall to the nursing staff. However, the nurses involved reviewed the electronic medical record and found no documentation of a recent fall, and after consulting with each other, did not proceed with a physical assessment. The resident was observed sleeping and did not verbalize pain during subsequent checks, leading staff to defer assessment and instead make a note in the physician communication book for evaluation the following day. No immediate nursing documentation or assessment was completed regarding the reported change in the resident's condition. The following morning, the resident was found to have increased pain and physical signs consistent with a left hip injury, including the left leg being rotated inward. Upon assessment by the DON and a nurse, the resident was sent to the hospital, where a left hip fracture was diagnosed and surgically treated. Interviews with staff and the resident confirmed that the resident did not initially report pain or the fall to staff, but did experience difficulty with mobility and later reported pain. The failure to assess the resident promptly after a change in condition and reports of a possible fall constituted the deficiency.