Failure to Assess Resident by RN After Fall Prior to Transfer
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care following a fall. According to the facility's policy, any injuries resulting from incidents or accidents are to be assessed by a licensed nurse or practitioner, and the affected individual should not be moved until it is deemed safe. However, after a resident with diagnoses including diabetes, heart failure, and obstructive uropathy experienced a fall, two nurse aides used a mechanical lift to return the resident to bed without first notifying or obtaining an assessment from a Registered Nurse (RN) or practitioner. The nursing notes and investigative report confirmed that the RN was not notified prior to moving the resident. The resident described the fall as occurring while preparing for bed, using a walker, and slowly slumping to the left side. The aide present ensured the resident was alright and, with another aide, used a lift to return the resident to bed. There was no documentation of an RN assessment prior to this transfer, which was contrary to both facility policy and the re-education provided to staff. The Director of Nursing confirmed that the required assessment was not completed before the resident was moved.