Failure of RN Supervisor to Complete Post-Fall Assessment and Incident Report
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) supervisor completed the post-fall incident report and assessment as required by facility policy for a resident who experienced an unwitnessed fall. The resident, who had a history of falls, hemiplegia, hemiparesis, aphasia, dementia, and mild intellectual disabilities, was found lying in the hallway and reported a fall. An initial assessment by an LVN documented a hematoma on the back of the resident's head, and the physician was notified, resulting in an order for a skull x-ray. Despite facility policy stating that the RN supervisor on duty must complete the Fall Incident Report within 24 hours and conduct a thorough post-fall assessment, the report was completed by the LVN instead. The RN supervisor, who was on lunch break at the time of the fall, did not conduct the required assessment or complete the incident report, stating he was unaware of the policy. The Director of Nursing confirmed that the RN supervisor was responsible for conducting a comprehensive assessment, even if an LVN had already performed an initial evaluation. Seven days after the fall, the resident complained of right shoulder pain and discoloration, leading to an x-ray that revealed a displaced, acute comminuted fracture of the right clavicle. The facility's Quality Assurance Nurse acknowledged that adherence to policy would have prompted an RN-level assessment, which could have identified injuries not detected during the LVN's assessment.