Failure to Ensure Nursing Staff Competency in Post-Fall Injury Response
Penalty
Summary
The facility failed to ensure that all nursing staff possessed the necessary competencies and skill sets to provide safe care for residents, as evidenced by an incident involving a resident with severe cognitive impairment and a history of falls. The resident, who was dependent on staff for toileting, dressing, bathing, and transfers, was found on the floor of her room after an unwitnessed fall from her wheelchair. She was discovered in significant distress, with her right lower extremity positioned abnormally near her face and her left upper extremity under her abdomen, crying and moaning in pain. Multiple staff members, including an LPN, responded to the scene. Despite the resident's obvious pain and abnormal limb positioning, the LPN on scene manipulated and repositioned the resident's right leg to what was perceived as a more natural alignment before emergency medical services arrived. This action was performed without a clear assessment of the injury's extent and without specialized training in managing potential fractures or dislocations. Several staff interviews confirmed that the LPN moved the resident's leg, which caused the resident to scream in pain. The LPN later stated that she acted to relieve the resident's pain, but acknowledged she was not trained to manipulate a potentially dislocated or fractured limb. Emergency medical personnel arrived and administered significant pain management interventions before attempting to move the resident, noting the severity of her pain and the obvious deformity of her leg. Hospital evaluation confirmed a right distal femur fracture with posterior displacement. Interviews with staff, including the DON and other nurses, revealed uncertainty and concern regarding the appropriateness of the LPN's actions, as well as a lack of clear guidance or competency in handling such situations. The incident resulted in actual harm to the resident, demonstrating a failure by the facility to ensure nursing staff were adequately trained and competent to respond appropriately to residents' needs following a fall with injury.