Failure to Assess and Document Resident After Fall
Penalty
Summary
The facility failed to assess a resident after a fall, as required by policy. A resident with a history of stroke, cognitive intactness, and significant physical impairments was dependent on staff for all activities of daily living. The resident self-reported rolling out of bed and hitting their left ribs, later experiencing left-sided pain and coffee brown emesis, which led to transport to the emergency room. There was no documentation of the fall in the medical record, and the required assessment for injuries, including vital signs and documentation, was not completed at the time of the incident. Interviews revealed that two CNAs and an LPN were present when the resident was moved back to bed after the fall, but no incident report was filed, and the fall was not communicated to nursing staff until the resident reported it. The administrator confirmed that the staff involved did not follow facility procedures for post-fall assessment and documentation, resulting in a lack of timely evaluation and notification to the physician and family as required by policy.