Failure to Notify Nurse and Assess Resident After Fall
Penalty
Summary
Certified nurse aides (CNAs) failed to notify a nurse before assisting a resident who had fallen back into bed, contrary to facility policy. On the date of the incident, two CNAs found a resident on the floor in a kneeling position by their bed and, at the resident's insistence, helped them back into bed without first alerting the nurse on duty. The nurse was only informed after the resident was already back in bed, and the reason for the check was not disclosed at that time. The facility's Fall Prevention Program policy requires that when a resident experiences a fall, staff must assess the resident, including a full body audit, before moving them. The resident involved had a history of muscle weakness, required assistance with personal care, and was dependent on staff for transfers. The resident also had moderate cognitive impairment and was at risk for falls due to multiple medical conditions, including confusion, deconditioning, gait and balance problems, and chronic illnesses. Interviews with the CNAs confirmed that they were aware of the policy to notify a nurse before moving a resident after a fall but did not follow it in this instance. The nurse on duty was not made aware of the fall until the following day, after the resident self-reported the incident. There was no documentation of the fall in the resident's medical record at the time of the incident, and the required assessment was not performed immediately after the fall.