Failure to Evaluate and Send Resident to Hospital After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a non-ambulatory resident with dementia was properly evaluated and sent to the hospital after being found on the floor. The resident had diagnoses including unspecified dementia, history of falling, essential hypertension, and hemiplegia/hemiparesis affecting the right dominant side, and required moderate assistance with transfers and used a wheelchair. The resident’s care plan identified a risk for falling related to a history of falls. During a night shift, a CNA found the resident on the bathroom floor around 1:15 a.m. and reported this to the nurse manager and an agency LPN. The CNA stated the resident was a new admission and she was not familiar with the resident’s abilities, and that she did not feel comfortable putting the resident back in bed due to fall risk. According to staff interviews, the nurse manager informed the agency LPN of the fall and instructed her to evaluate the resident. The nurse manager recalled asking the agency LPN if an ambulance should be called, but the agency LPN stated the resident was okay and had not fallen, asserting that the resident had walked to the restroom. The CNA reported that after cleaning the resident, she placed the resident in a geriatric chair in the hallway on 1:1 observation, and that the agency LPN took the resident’s blood pressure. No incident report was completed at that time, and the event was not treated or documented as a fall. The agency RN who worked the following day reported not being informed of any fall, special monitoring, or neurological checks for the resident, and only being called later to medicate the resident for leg pain. Subsequently, another LPN coming on duty was informed by the resident’s roommate that the resident had been found on the bathroom floor during the prior night. This LPN assessed the resident, observed a bruise on the leg, and contacted the physician, receiving orders to send the resident to the hospital for further evaluation. A late entry nursing progress note by the agency LPN later documented that she had been called to the room and observed the resident sitting on the bathroom floor, with the resident denying a fall and stating she was trying to clean herself. The facility’s incident report and hospital documentation show that the resident was ultimately admitted to the hospital with complaints of right leg pain, sepsis, and a comminuted, displaced fracture of the distal third of the clavicle, with the hospital record indicating admission for a fall with clavicle fracture. Facility policies required prompt investigation of incidents, assessment for injury, and seeking medical intervention when necessary, as well as clinical protocols for falls that included physician identification of conditions affecting fall risk and complications.
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