Failure to Assess and Notify Physician After Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess a resident after a fall and did not notify the physician in a timely manner. The resident, who had a history of cognitive communication deficit, dementia, depression, anxiety, and a previous femur fracture, was found on the floor by his roommate after a fall. The resident was unable to explain what happened, had severely impaired cognition, and complained of left hip pain. Although a head-to-toe assessment was documented with no visible injuries, the resident was unable to stand, and staff assisted him back to bed and provided pain medication. The facility's fall investigation revealed that the resident's range of motion was not assessed following the fall, and the physician was not notified until several hours later. Interviews with the DON and a CNP confirmed that the range of motion assessment was omitted and that the physician notification was delayed, both of which should have occurred immediately after the incident. This deficiency was identified during a review of falls and related care for residents at risk.