Failure to Notify RN and Assess Resident After Fall
Penalty
Summary
A resident with diagnoses of schizophrenia, dementia, falls, and impaired mobility, who required maximum assistance for bed mobility and was dependent for transfers, experienced an unwitnessed fall during the night. The resident, who had severely impaired cognition, was found on the floor by a nurse aide who, without notifying the charge nurse or RN supervisor, picked the resident up and placed them back in bed. The resident later complained of pain and was found to have a displaced fracture of the left humerus. The nurse aide admitted to not reporting the fall to nursing staff and to moving the resident without an RN assessment, despite knowing facility policy required notification and assessment before moving a resident after a fall. The RN supervisor on duty was unaware of the fall until informed later by management, and confirmed that the nurse aide should have reported the incident so an RN assessment could be completed. Facility documentation and interviews confirmed that the resident required two staff and a mechanical lift for transfers, and that the nurse aide acted alone and failed to follow protocol. The facility's falls management policy defined a fall as any instance of a patient found on the floor and required immediate reporting and assessment, which was not followed in this case.