Failure to Document, Report, and Monitor After Resident Fall Resulting in Harm
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, chronic kidney disease, diabetes, and major depressive disorder fell out of bed. The Registered Nurse Supervisor assessed the resident and assisted in returning them to bed using a Hoyer lift. However, the nurse failed to document the fall in the electronic medical record, did not complete a facility Occurrence Report, and did not notify the physician or the resident's family as required by facility policy. As a result, the incident was not communicated to the appropriate parties, and the resident was not monitored for pain or injury following the fall. Two days after the fall, staff observed bruising and swelling on the resident's right leg, accompanied by decreased range of motion and pain. The resident was subsequently sent to the hospital, where a fractured right femur was diagnosed. The lack of timely documentation and notification meant that the resident did not receive appropriate follow-up care or monitoring for potential injuries in the immediate aftermath of the fall. Interviews with staff confirmed that the Registered Nurse Supervisor did not report or document the incident at the time, citing being occupied with other duties. The Director of Nursing and Administrator both acknowledged that the nurse failed to follow established policy for reporting and documenting incidents. The deficiency resulted in actual harm to the resident, as the injury was not identified or treated promptly.