Resident Transferred After Fall Without Required Assessment
Penalty
Summary
A resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, dementia, PTSD, delirium, and anxiety, experienced two falls in one day. After the second fall, the resident was found sitting on the floor, complaining of pain in the right thigh/hip. According to the facility's Post Fall policy, staff are required to conduct a comprehensive evaluation, including assessment for symptoms such as numbness, tingling, or pain, before moving a resident after a fall. If certain symptoms are present, the policy directs staff not to move the resident and to notify a provider or call 911. In this incident, the LPN assisted the resident to a supine position and, with the help of other staff, transferred the resident from the floor to the bed using Hoyer slings before completing a full physical assessment. The nursing progress note and staff interviews confirm that the resident was moved prior to a comprehensive assessment, despite the resident's complaint of hip pain and a pending X-ray order from an earlier fall. The Nursing Home Administrator stated that the facility's policy requires vital signs and pain assessments before transferring a resident unless there are obvious signs of severe injury. However, the administrator was unaware that the injury information pertained to the first fall and that a second fall had occurred. The transfer of the resident from the floor to the bed was performed while the resident was experiencing pain and before the results of the pending X-ray were available, which was not in accordance with the facility's policy.