Failure to Document and Communicate Fall with Injury
Penalty
Summary
Facility staff failed to follow standards of practice in the assessment, documentation, and communication of a resident's fall with injury. A resident with a history of dementia, atrial fibrillation, repeated falls, and on anticoagulant therapy experienced a fall from bed, hitting their head and sustaining a hematoma. Although the fall was witnessed and initially assessed by nursing staff, there was no documentation of the incident, assessment, or physician notification in the resident's medical record for several days following the event. Multiple staff members, including RNs and LPNs, were aware of the fall but each assumed that another staff member would complete the required documentation and follow-up. As a result, essential post-fall monitoring, including neurological checks and ongoing assessments, were not consistently performed or communicated to subsequent shifts. The lack of documentation and handoff led to staff on following shifts being unaware of the need for fall follow-up monitoring, and the physician was not promptly notified as required by facility policy. Interviews with staff and review of records confirmed that the facility's fall prevention policy, which requires immediate assessment, documentation, physician and family notification, and 72-hour follow-up monitoring after a fall, was not followed. The deficiency was further compounded by a recent transition to a new electronic documentation system, which some staff cited as a reason for confusion about where to document. The failure to document and communicate the fall and subsequent injury resulted in delayed recognition and management of the resident's condition.