Failure to Document Post-Fall Assessment After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when the facility failed to conduct and document a comprehensive assessment for a resident following an unwitnessed fall. The resident, who had a diagnosis of unspecified dementia and resided on the dementia unit, was found on the floor with a pool of blood at his head and was yelling for help. Although the incident report included vital signs, it did not document a range of motion (ROM) or neurological assessment, despite the presence of an obvious head injury. The resident complained of right hip pain and was unable to bear weight on the right hip before being sent to the emergency room, where a closed right hip fracture was diagnosed. Interviews with staff revealed that while some assessment attempts were made, such as checking vital signs and attempting to assess ROM and pupils, these were not documented in the medical record. The RN involved acknowledged that the assessments should have been documented, especially given the resident's complaints of pain and visible injuries. The Director of Nursing confirmed that the required assessments, including ROM and neuro checks, were missing from the documentation. The facility did not have a specific policy for post-fall assessments, but staff agreed that documentation of these assessments was expected.