Failure to Document and Report Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to document and report a fall for one resident who was at risk for falls and had multiple medical conditions, including Parkinson's disease, dementia, and a history of unsteady gait. The resident was found sitting on the floor in his room, working on his wheelchair, by certified nurse assistants (CNAs) during a bed check. The CNAs notified the registered nurse (RN) on duty, who assessed the resident and noted no immediate complaints of pain or distress. However, the RN did not consider the incident a fall, did not complete a fall assessment or incident report, and did not notify the physician or the resident's family at that time, as required by facility policy. Subsequently, the resident began to complain of pain later in the morning, prompting the oncoming licensed practical nurse (LPN) to assess the resident and contact the physician for an x-ray. The x-ray revealed a subcapital right femoral neck fracture. The physician then ordered the resident to be sent to the hospital for evaluation and treatment. Interviews with staff revealed inconsistent accounts regarding the timing of the incident and the actions taken, with some staff stating the resident was not moved until after the RN's assessment, while others indicated the resident was assisted without immediate nurse notification. The resident's family was not informed of the fall until after the fracture was discovered. Facility policy required that any time a resident is found on the floor, it should be treated as a fall, with immediate assessment, documentation, and notification of the physician and family. The failure to recognize and report the incident as a fall resulted in a lack of timely documentation, assessment, and notification, contrary to established protocols. The deficiency was further compounded by the staff's misunderstanding of what constitutes a fall and the absence of a care plan addressing the resident's behavior of sitting on the floor.