Resident Moved After Fall in Violation of Post-Fall Protocol
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff did not move a resident after a fall, contrary to facility policy and professional standards of quality. The resident had dementia, a history of falls, muscle weakness, difficulty walking, and was care planned as a fall risk requiring assistance of one staff for stand-pivot transfers, while being independent with wheelchair mobility. The resident wheeled themself into the shower room to use the toilet without calling for assistance and experienced an unwitnessed fall, ending up on the floor with the commode frame on top and the right leg bent under the left leg. The resident complained of right hip pain, and the right hip appeared dislocated with swelling. A charge nurse, responding to a loud noise, found the resident on the floor with the commode frame on top of them and a nursing assistant standing over the resident. According to the facility’s report and staff interviews, the nursing assistant removed the commode frame from the resident and then attempted to move the resident’s legs using her foot, despite the resident’s complaints of pain and the nurse’s direction not to move the resident. The RN supervisor reported observing the nursing assistant try to move the resident’s foot/leg with her own foot after being told not to move the resident, which caused the resident to call out in pain. The nursing assistant acknowledged that she tried to uncross the resident’s legs by placing the sole of her shoe on the resident’s foot to guide the leg, and admitted she knew she was not supposed to move a resident after a fall, though she could not explain why she did so or why she used her foot. The DON confirmed that the nursing assistant attempted to move the resident’s legs after the fall, that this caused the resident pain, and that the assistant should not have moved the resident or used her foot, in conflict with the facility’s Falls, Management and Prevention Policy, which directs that residents are not to be moved prior to a nurse’s assessment following a fall.
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