Failure to Ensure RN Assessment After Resident Fall
Penalty
Summary
A deficiency was identified when a licensed practical nurse (LPN) failed to adhere to facility policy and state regulations regarding post-fall assessment for a resident with diagnoses including orthostatic hypotension, history of stroke, and glaucoma. After the resident was found on the floor following a fall, the LPN noted the incident and placed the resident back into his chair without an assessment by a registered nurse (RN), as required by the facility's Falls Management Program policy. The RN supervisor was notified, but did not assess the resident, and there was no documentation of an RN assessment in the clinical record or facility documentation. Further review and staff interview confirmed that the LPN did not directly notify the RN supervisor of the fall, and the resident was transferred before an RN assessment was completed. The facility's Director of Nursing acknowledged that the required RN assessment did not occur. This failure to follow established policies and procedures resulted in noncompliance with Pennsylvania Code Title 49 and facility protocols for post-fall care.