Failure to Assess and Monitor Resident After Falls
Penalty
Summary
The facility failed to ensure that a resident was properly assessed and monitored following two fall incidents. According to the facility's policy, staff are required to evaluate residents for possible injuries, record vital signs, notify the physician, and document any observed symptoms after a fall. However, after a resident with dementia, anxiety, mild intellectual disabilities, lack of coordination, and dysphagia experienced two falls, there was no evidence in the clinical record that nursing staff performed any assessments or documented the incidents. The nursing supervisor who discovered the resident on the floor did not complete an assessment, stating it was the responsibility of the next shift. The licensed nurse on the following shift also did not perform or document any assessment after witnessing the resident slide off the chair and fall again shortly after. Additionally, there was no documentation that the resident's physician was notified of either fall at the time they occurred. The physician confirmed that notification was not received until several days later, despite facility policy requiring timely notification. The lack of assessment, documentation, and physician notification following the falls was confirmed through staff interviews, review of clinical records, and facility documents.