Failure to Follow Fall Assessment Protocol by LVN
Penalty
Summary
The facility failed to ensure that a licensed vocational nurse (LVN) demonstrated the required competencies and skill sets necessary to care for a resident following a fall. Specifically, after being informed by a certified nurse aide (CNA) that a resident was found on the floor, the LVN entered the room and observed the resident with a head injury. The LVN instructed the CNA to transfer the resident from the floor to the bed before conducting a head-to-toe assessment or obtaining vital signs, which was contrary to the facility's fall protocol and training. The resident involved had a history of Alzheimer's disease, poor memory, disorganized thinking, and was at risk for falls due to lack of safety awareness and coordination. The care plan identified the resident as requiring moderate assistance with transfers and at risk for falls. The facility's fall protocol, which the LVN had been in-serviced on, required that residents not be moved after a fall until a thorough assessment and vital signs were completed to check for injuries such as fractures or other complications. Interviews with the LVN, CNA, and Director of Nursing confirmed that the LVN did not follow the established protocol, as the assessment and vital signs were only completed after the resident was moved. The LVN acknowledged forgetting the protocol and stated she was aware of the correct procedure from previous training. The Director of Nursing reiterated that the expectation was for assessments and vital signs to be completed prior to moving any resident after a fall, and that the LVN did not adhere to this requirement.