Failure to Protect Resident from Neglect After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to protect a resident's right to be free from neglect following an unwitnessed fall with a head injury. The resident, who had a history of muscle weakness, unsteadiness, and required assistance for mobility, experienced an unwitnessed fall in the evening. The nurse on duty assessed the resident and noted redness on the back of the head/neck area but did not complete or document ongoing neurological checks as required by facility policy. Additionally, there was no documentation of family or physician notification regarding the fall, and the facility's fall protocol and the resident's person-centered care plan were not followed. The medical record review revealed that neurological monitoring was only initiated for a short period and was incomplete, with the remainder of required checks not performed or documented. The nurse did not complete an incident report, and the post-fall evaluation, including assessments for delayed complications and changes in the resident's condition, was not conducted. The resident was found unresponsive the following morning and subsequently passed away. Interviews with staff confirmed a lack of communication and understanding of the facility's fall protocol, as well as insufficient training and knowledge regarding required post-fall assessments and documentation procedures. Further interviews with facility leadership and staff indicated that the nurse responsible for the initial assessment lacked adequate training on the facility's electronic medical record system and was unaware of the full scope of required post-fall procedures. The failure to follow established protocols, conduct ongoing monitoring, and communicate with the physician and family constituted neglect, as defined by facility policy and federal regulations. The deficiency was identified as Immediate Jeopardy due to the systemic failures in assessment, documentation, and communication following the resident's fall.