Failure to Respond and Document Unwitnessed Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to respond appropriately to an unwitnessed fall involving a male resident with a history of repeated falls, severe cognitive impairment, and multiple comorbidities including impulse disorder, cerebral infarction, muscle weakness, bipolar disorder, and chronic kidney disease requiring dialysis. The resident was found on the floor in his room by a maintenance director and a visitor, who reported the incident to nursing staff at the nurse's station. Despite being notified, the nursing staff delayed their response, with reports indicating a wait of several minutes before the resident was assisted. During this time, the resident was observed face down on the floor with a pillow under his head, calling for help, and his call light was not within reach. The incident was not documented in the resident's medical record, progress notes, or incident reports. There was no evidence that the fall was reported to the DON, physician, or the resident's representative. Interviews with staff revealed inconsistent accounts regarding the response time and actions taken following the report of the fall. Some staff dismissed the event as a behavioral issue, referencing the resident's care plan, which noted a tendency to self-transfer and lie on the floor, but did not include specific interventions for supervision or documentation of such events. The lack of documentation and notification was contrary to facility policy, which requires all falls, including unwitnessed ones, to be assessed, documented, and reported. Further review of the resident's care plan and fall risk assessments showed a pattern of previous falls, but no interventions addressing supervision outside or specific documentation protocols for unwitnessed falls. The facility's policies define a fall as any unintentional change in position to the floor and require immediate assessment, documentation, and notification of appropriate parties. The failure to follow these protocols resulted in the event not being properly managed or communicated, as required by professional standards of practice.