Failure to Communicate and Document Change in Condition After Resident Fall
Penalty
Summary
The facility failed to identify, document, and communicate changes in condition for a resident following an unwitnessed fall. Certified Nursing Assistants (CNAs) observed new onset of shoulder pain and limited range of motion in the resident while assisting with dressing on two separate occasions, but did not effectively communicate these changes to the Licensed Vocational Nurse (LVN) and did not complete the required Stop and Watch form, which is the facility's designated CNA-to-LVN communication tool. Additionally, one CNA stated she verbally notified the LVN but did not document the change, while another CNA admitted to forgetting to complete the form. The LVNs involved reported not being made aware of the resident's pain or range of motion limitations, and as a result, did not perform further assessments or notify the physician for further evaluation. On a separate occasion, an LVN noted new skin redness to the resident's right shoulder three days after the fall but failed to document the finding, assess for range of motion changes, or notify the physician or RN Supervisor. The LVN stated that the omission was due to being busy with medication administration. The lack of documentation and communication meant that other licensed nurses and the physician were not made aware of the resident's new symptoms, and no change of condition note was initiated. Interviews with other staff confirmed that the facility's policy required such findings to be documented and communicated promptly, especially following a fall. The resident involved had a history of falling, hemiplegia, hemiparesis, aphasia, dementia, and mild intellectual disabilities, and required moderate assistance with activities of daily living. The resident's care plan specified that nurses were to call the physician for any significant change of condition and assess for nonverbal signs and symptoms of pain. Despite these requirements, the new onset of pain and functional decline was not effectively communicated or documented, resulting in a delay in physician notification and the discovery of a clavicle fracture and significant bruising several days after the initial fall.