Failure to Notify Nurse and Improper Movement of Resident After Fall
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow facility policy and procedure regarding the response to resident falls. Upon finding a resident with severe cognitive impairment, muscle weakness, osteoporosis, and a history of falls lying on the floor, the CNA lifted the resident and returned her to bed without notifying a licensed nurse or waiting for a nurse's assessment. The CNA did not immediately report the incident to the licensed nurse, delaying notification by approximately 20 minutes. During this time, the resident was not assessed for injuries by a licensed nurse as required by facility policy. When the licensed nurse was finally notified and assessed the resident, she found the resident in bed, shivering and shaking in pain, with a swollen and discolored left foot. Subsequent X-ray imaging confirmed an acute nondisplaced distal fourth metatarsal neck fracture, with a possible additional fracture. The resident's care plans and assessments indicated she was at high risk for falls and fractures, required maximal assistance for mobility and transfers, and was to be handled gently to prevent injury. The facility's policy and CNA job description both required immediate notification of a licensed nurse and that residents not be moved after a fall until assessed by a nurse. Interviews with staff, including the CNA, licensed nurses, and the Director of Nursing, confirmed that the CNA did not follow established procedures. The CNA admitted to moving the resident without assistance and without notifying a nurse, stating he did not observe pain at the time and did not seek help because other staff were busy. The Director of Nursing and other nursing staff emphasized that moving a resident after a fall without a nurse's assessment could worsen injuries, and that the CNA's actions were not in accordance with facility policy.