Failure to Assess and Document Post-Fall Care
Penalty
Summary
A resident with a history of unsteadiness and falls was involved in an incident where they fell from their wheelchair to the floor. The fall occurred on a Friday, and both the resident and a nursing assistant confirmed the event. Despite this, there was no documentation of the fall in the resident's medical record, nor was there evidence of an assessment, initial or ongoing vital signs, neurological checks, or monitoring for latent injury as required by facility policy. The assigned nurse did not question the resident about the incident, did not perform an assessment, and did not notify the provider. The resident began experiencing significant pain the day after the fall, which escalated to severe back pain by Sunday. The resident was eventually sent to the hospital, where a compression fracture of the L2 vertebrae was diagnosed. Documentation showed that the resident received pain medication for increasing pain, but there was no record of post-fall evaluation or provider notification until the resident's pain became excruciating and they were unable to get out of bed. Interviews with staff and the Director of Nursing confirmed that the incident met the facility's definition of a fall and that required post-fall procedures were not followed. The facility was unable to provide evidence of any evaluation or provider notification following the fall, in direct violation of their fall management and significant change policies.