Failure to Timely Report and Assess Resident Fall Resulting in Harm
Penalty
Summary
A deficiency occurred when staff failed to timely report a fall, complete a thorough and prompt assessment, and provide timely care and treatment after a resident experienced a fall. The incident involved a resident with a history of hemiplegia, morbid obesity, dementia, and other significant medical conditions, who was at high risk for falls and required substantial to maximal assistance for mobility and transfers. The resident fell out of bed during the night and was assisted back into bed by staff without a nurse assessment or proper documentation of the event. Following the fall, the resident complained of bilateral leg pain, but this was not immediately reported to the nurse. The resident was also noted to have vomited during the early morning hours, which was reported to the nurse later. The day shift staff were not informed of the fall, and the incident was not documented in the progress notes or communicated during shift change. It was only when the day shift CNA attempted to provide care and the resident screamed in pain that a nurse was notified, leading to a thorough assessment, x-rays, and eventual transfer to the hospital. The delay in assessment and reporting resulted in the resident being diagnosed with bilateral femur fractures, requiring surgical intervention. Interviews with staff revealed confusion about what constitutes a fall and the appropriate post-fall procedures, including the need for a nurse assessment before moving a resident and timely notification of medical providers and family. The facility's fall management policy was not followed, as immediate needs were not assessed, and the incident was not promptly reported or documented.