Failure to Assess and Complete Fall Risk Assessment After Resident Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to fully assess a resident following a fall that resulted in pain and possible injury before transferring the resident back to bed. The resident, who had multiple diagnoses including muscle weakness, cognitive communication deficit, anxiety, depression, and schizoaffective disorder, was identified as being at high risk for falls. The care plan included interventions such as a low bed, encouraging the resident to request staff assistance for transfers and toileting, and therapy evaluations. Despite these interventions, the resident experienced an unwitnessed fall and was found on the floor complaining of severe left hip pain, with visible erythema and limited range of motion in the left lower extremity. Upon discovering the resident on the floor, staff, including an LPN, a nurse aide, and an RN, assisted the resident back to bed before a thorough assessment was conducted. The resident expressed significant pain during the transfer, repeatedly yelling out, but the staff proceeded to move the resident from the floor to a wheelchair and then to bed. The RN only performed a full assessment after the resident was back in bed, at which point the resident continued to exhibit pain with movement. Subsequent imaging revealed an acute left femoral intertrochanteric fracture, and the resident was later transferred to the hospital for surgical intervention. Additionally, a review of the clinical record showed that fall risk assessments were not completed as required by facility policy, either prior to or after the fall, despite the resident having a history of multiple falls. Facility policy mandated that fall risk assessments be performed upon admission, quarterly, annually, and after any change in condition, including after a fall. Interviews with staff and the DON confirmed that these assessments were not completed as required, and the resident's care plan was not updated with targeted interventions based on a current assessment.