Failure to Report Fall and Initiate Neurological Assessment
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to report an unwitnessed fall involving a resident with diagnoses including dementia, Parkinson's Disease, and epilepsy. After discovering the resident on the floor, CNA 1 assisted the resident back into bed without notifying a licensed nurse or supervisor, as required by the facility's job description for CNAs. The resident later informed a Licensed Vocational Nurse (LVN) about the fall, which led to delayed awareness and response by facility leadership. The facility did not have a policy or procedure outlining the steps to take when a resident is found on the floor. Following the delayed report of the fall, the facility failed to initiate a neurological assessment as required by their own policy. The resident's neurological status was not evaluated after the fall was reported, and no assessment was performed prior to the resident's transfer to a General Acute Care Hospital for further evaluation and treatment. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), confirmed that a neurological assessment should have been conducted after learning of the fall, but this was not done.