Failure to Follow Fall Reporting and Assessment Policy
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow facility policy and procedure after finding a resident on the floor in her room. The CNA did not report the incident to the nurse in charge and instead assisted the resident up from the floor, placed her in a wheelchair, and took her to the dining room for breakfast. The resident was not assessed by a licensed nurse prior to being moved, contrary to facility policy which requires a nurse assessment before moving any resident found on the floor. The resident involved was an elderly female with a history of hypertension, non-Alzheimer's dementia, cerebrovascular accident, and repeated falls. She had severe cognitive impairment, used a wheelchair for mobility, and required assistance with transfers and activities of daily living. Her care plan specified that she was at risk for falls and required one-person assistance for transfers, use of a gait belt, and immediate nurse notification if a fall or injury occurred. Despite these interventions, the CNA did not follow the care plan or facility policy when the resident was found on the floor. Interviews and record reviews confirmed that the CNA was aware of the policy to leave residents in place and notify a nurse if found on the floor, but did not comply. The incident was only discovered when the resident's responsible party observed the event on a camera and notified the facility. The nurse was not informed until after the responsible party's call, at which point the resident was assessed and appropriate documentation was completed. The failure to follow established procedures resulted in the resident not being assessed for injuries in a timely manner.