Failure to Provide Timely Post-Fall Assessment and Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a fall. The resident, who was at high risk for falls and dependent on staff for all transfers, was found on the floor in her room after an unwitnessed fall. There was no documentation in the progress notes of the fall or a post-fall evaluation on the date of the incident, despite facility policy requiring such documentation. Staff did not perform or document a timely assessment, and the fall was not reported to the physician or the resident's family as required. Following the fall, the resident exhibited signs of pain and swelling in her leg, which were noticed by family members and reported to staff. Multiple staff interviews revealed that the resident's pain was reported to the nurse on duty, but no action was taken to assess or address the resident's condition. The nurse involved did not assess the resident after the fall, nor did she notify the family or physician, and the resident continued to display symptoms over the following days. The resident was eventually sent to the hospital at the request of her family, where she was diagnosed with fractures in her left femur and right hip. The lack of timely assessment, monitoring, and reporting after the fall resulted in a delay in treatment for the resident's injuries. The facility's failure to follow its own fall guidelines and professional standards of care led to the deficiency cited in the report.