Failure to Assess and Document Resident After Fall
Penalty
Summary
The facility failed to ensure that a resident was properly assessed following an alleged fall. The resident, who had severe dementia, anxiety, and depression, was found sitting on the floor in her room and reported she had fallen but could not recall the details. Certified Nursing Assistants notified an LPN of the incident, but the LPN did not immediately assess the resident and instructed staff to return her to bed. The resident was later sent to the emergency department, where she was diagnosed with closed fractures of the 8th and 9th ribs on the right side. There was no documentation in the nursing progress notes regarding the fall, assessment, notifications, or the time the resident was sent to the emergency department. Further interviews revealed that the LPN who received the resident back from the emergency department was not informed of the fall and found no documentation in the notes. The Assistant Director of Nursing confirmed that the facility's policy requires immediate assessment and documentation after a fall, including a detailed progress note and notifications. The facility's post-fall procedure was not followed, as there was no evidence of a fall risk evaluation, assessment, or proper documentation in the resident's record.