Failure to Provide Timely Post-Fall Assessment and Care
Penalty
Summary
A deficiency occurred when a resident with advanced dementia, osteoporosis, and a history of falls experienced a fall and did not receive timely or adequate post-fall assessment and care according to professional standards and the resident's care plan. The resident, who was non-verbal and required substantial assistance with transfers, fell while being assisted to the restroom without a gait belt. The care plan and recent physical therapy evaluation indicated a need for a two-person assist for transfers, but this was not communicated to or followed by staff, resulting in a one-person assist at the time of the fall. Following the fall, the initial assessment by nursing staff did not identify pain or significant injury, and only a minor skin abrasion was documented. However, over the next 48 hours, multiple staff members observed the resident displaying non-verbal signs of pain, such as facial grimacing and difficulty with transfers. Despite these observations, there was a lack of consistent and thorough post-fall assessments, including range of motion (ROM) and pain assessments, as required by facility policy. Documentation of pain assessments and the effectiveness of PRN Tylenol administration was also missing. Communication with the nurse practitioner (NP) was delayed, and the NP was not notified of the resident's pain symptoms until nearly two days after the fall. The resident remained in pain and with an untreated hip fracture for up to 48 hours before being sent to the emergency room, where a left femoral neck fracture was diagnosed. Interviews with staff revealed gaps in communication, incomplete documentation, and a lack of adherence to post-fall protocols. The care plan was not updated to reflect the increased assistance required for transfers, and staff were not consistently aware of or following the resident's current care needs. These failures resulted in a delay in identifying and treating a significant injury.