Failure to Document and Follow Up After Resident Fall
Penalty
Summary
Facility staff failed to follow their policy and procedure on charting and documentation in accordance with professional standards of practice for one resident. After a fall occurred when the resident's wheelchair was tilted backwards by staff, resulting in the resident falling and hitting the back of his head and neck, staff did not complete thorough documentation of the incident or possible injuries. The initial progress notes and SBAR post-fall documentation were incomplete, lacking detailed descriptions of the event, assessments, and interventions performed. The resident refused vital signs at the time, but the documentation did not reflect a comprehensive assessment or follow-up. Additionally, although x-rays were ordered immediately after the fall, the cervical spine x-ray results were not followed up for three weeks. The radiology report was incomplete, and there was no indication in the medical record that staff obtained or reviewed the final results for the cervical x-ray. Interviews with nursing staff and the DON confirmed that the documentation was incomplete and that the process for following up on diagnostic results was not adhered to, leaving the possibility of an undiagnosed injury. The resident, who had a history of cervical spine fusion, functional quadriplegia, chronic pain syndrome, and spinal stenosis, reported increased pain following the fall, which was not adequately addressed in the documentation. The facility's policy required complete, objective, and accurate documentation of all services, changes in condition, and incidents, but this was not met in the handling of the resident's fall and subsequent care.