Failure to Ensure Competent Nursing Assessment and Timely Response After Resident Fall
Penalty
Summary
Nursing staff failed to demonstrate the necessary competencies and skills to provide safe and appropriate care for a resident who experienced an unwitnessed fall resulting in head injuries. The facility's own assessment and policies required staff to possess and apply appropriate skills and competencies, including conducting thorough assessments and timely interventions following resident falls. However, after the resident's fall, staff did not recognize or document the extent of the injuries, and assessments were performed inadequately, including conducting neurological checks in poor lighting conditions, which staff later acknowledged was not appropriate. The medical record and facility investigation revealed that the resident, who had multiple diagnoses including cerebral infarction, seizures, and poor mobility, was not properly assessed after the fall. Despite visible injuries such as swelling and hematomas to the face and head, there was a significant delay in transferring the resident to the emergency room for evaluation. The Family Nurse Practitioner (FNP) identified the injuries and gave an order for transfer, but the resident was not sent to the hospital until approximately seven hours later. Documentation was lacking regarding the timing of EMS notification and the specific assessments performed after the fall. Interviews with facility staff, including LPNs, RNs, the ADON, DON, and the FNP, revealed confusion and inconsistency regarding protocols for post-fall assessment, documentation, and emergency transfer procedures. Staff admitted to performing assessments in the dark, being unsure of the resident's baseline appearance, and not following established protocols for head injuries. The delay in recognizing the severity of the resident's injuries and the failure to promptly transfer the resident for medical evaluation resulted in actual harm.