Failure to Provide Adequate Supervision and Timely Reporting After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, hemiparesis, a history of falls, and dependence for transfers was left unattended in his wheelchair in his room by a CNA. The CNA had wheeled the resident from the nurse's station to his room and left him there while seeking assistance for a transfer. During this time, the CNA was distracted by another resident's request and left the area. Upon returning, the CNA found the resident on the floor, having sustained an unwitnessed fall. Following the fall, the CNA, with the assistance of a Med-Aide, transferred the resident back to bed using a bed sheet, without notifying a nurse or having the resident assessed for injuries. The Med-Aide assumed the CNA had already reported the incident and that it was safe to move the resident. During the transfer, the resident was noted to be moaning, and after being placed in bed, continued to express pain, but neither staff member reported the incident to nursing staff at that time. The incident was only discovered when the incoming CNA for the next shift was informed by the resident that he had fallen and was experiencing pain. The incoming CNA immediately notified the LVN, who assessed the resident and initiated appropriate medical interventions. It was later confirmed that the resident had sustained a right hip fracture as a result of the unwitnessed fall. Both the CNA and Med-Aide involved admitted to not following facility protocols regarding fall reporting and resident assessment after a fall.