Failure to Ensure Nursing Staff Competency in Post-Fall Assessment and Notification
Penalty
Summary
Nursing staff at the facility failed to demonstrate the necessary competencies and skills to provide safe and appropriate care for a resident who experienced an unwitnessed fall. The resident, who had a history of muscle weakness, unsteadiness, and mobility issues, was found to have fallen and sustained redness to the back of his head and neck. Despite these findings, there was no documented evidence that neurological checks were properly conducted, nor that the resident’s family or physician were notified of the incident. The nurse involved did not complete the required post-fall assessments or incident report, and only provided an oral report to the DON. The nurse also lacked knowledge of the facility’s fall protocol, procedures, and the use of the EMR system, having received only minimal training before being assigned as charge nurse. Further review revealed that the last documented fall risk or post-fall evaluation for the resident was not completed for the most recent fall, and there was no follow-up for delayed complications related to the incident. The neurological monitoring initiated was incomplete, and subsequent checks were not performed as required. Other staff, including the RN on the following shift, were not informed of the fall and therefore did not continue necessary monitoring. Interviews with facility leadership confirmed that the fall protocol was not followed, care plan interventions were not implemented, and required documentation was missing. The facility’s policies required immediate and ongoing assessment, documentation, and notification following a fall, none of which were adequately carried out in this case. The resident was later found unresponsive and subsequently passed away after being transported to the hospital. Interviews with family members indicated they were not notified of the fall until after the resident was sent to the hospital. The physician also confirmed he was not informed of the fall. Facility leadership acknowledged that the expected protocols and procedures were not followed, and that the nurse involved did not possess the necessary competencies to perform required assessments or documentation. The failure to ensure staff competency and adherence to protocols placed residents at risk for significant harm.