Failure to Timely Report, Assess, and Monitor Resident After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical conditions experienced an unwitnessed fall that was not promptly reported, assessed, or documented by facility staff. The resident was found on her knees at the side of her bed by CNAs during shift change, and although the CNAs assisted her into her wheelchair and informed a nurse about a knee abrasion, they did not explicitly report the incident as a fall. The nurse, upon being notified, did not recognize the event as a new fall and therefore did not initiate the facility's fall protocol, which includes immediate assessment, documentation, and notification of the provider and responsible party. The lack of clear communication and understanding among staff led to a delay in recognizing and responding to the fall. The incident was not documented as a fall until several days later, after the resident's family noticed new injuries and raised concerns with facility leadership. During this period, required post-fall assessments, monitoring, and notifications were not completed. The resident's medical record did not reflect the fall or the resulting injuries in a timely manner, and the facility's point-of-care documentation failed to note any new skin issues or injuries during routine checks. Interviews with staff revealed confusion about the reporting process and a lack of awareness regarding the resident's fall. The nurse involved believed the knee injury was related to a previous incident and did not initiate the necessary protocols. The delay in identifying and reporting the fall resulted in a lack of comprehensive assessment and monitoring for the resident, as well as delayed notification to the provider and family. The deficiency was identified through a combination of family complaints, staff interviews, and record reviews, which confirmed that the facility failed to ensure timely reporting, notification, comprehensive assessment, and continued post-fall monitoring following the unwitnessed fall.