Failure to Timely Notify Family and Physician and Complete Post-Fall Assessment After Lift Incident
Penalty
Summary
The deficiency involves the facility’s failure to timely notify a resident’s family/representative and physician of a significant change in condition following a fall from a mechanical ceiling lift, as well as incomplete post-fall assessment and documentation. The facility’s Falls – Clinical Protocol required that families be notified of all falls but did not specify a timeframe for notification or address post-fall assessments, monitoring, or documentation. For the involved resident, who had severe cognitive impairment, a history of falls, arthritis, non-Alzheimer’s dementia, anxiety disorder, muscle weakness, and dependence on staff for all transfers and ADLs, there was no documentation of a post-fall assessment, post-fall skin assessment, or timely communication to the physician or representative on the date of the incident until late in the afternoon. On the day of the incident, the resident, who was care planned as a Hoyer lift transfer and at risk for falls, was being transferred from bed to a Geri chair with a portable ceiling lift by a CNA. The CNA reported that the lift broke and the resident began to come down, so the CNA grabbed the resident, slid the resident against the CNA’s body, and lowered the resident to a seated position on the floor. Another CNA responded to yelling, found the resident seated on the floor in front of the first CNA, and together they used a gait belt and a fireman lift to move the resident to a Geri chair. Both CNAs reported no immediate distress and did not immediately notify the nurse, with one CNA stating the nurse was busy and they did not feel the resident was injured, and the other CNA acknowledging awareness that immediate notification should have occurred. RN C later entered the room to perform a throat swab and assessed the resident, reportedly noting no injuries or immediate distress at that time, but did not document this assessment in the progress notes. Mid-morning, staff observed bruising and discomfort in the resident’s right lower extremity, and the physician was contacted for a STAT x-ray order. Documentation shows that family notification of the fall and physician contact were not recorded until late afternoon, and there were no progress notes on the date of the incident addressing a head-to-toe assessment, family contact, or a detailed description of the incident. The resident’s responsible party reported not being informed of the fall until early afternoon, despite a spouse being present in the facility earlier that morning and not being told of the incident. Facility leadership, including the DON, Nursing Manager, and Administrator, stated their expectation that nurses immediately assess residents and contact the physician and family after a fall, which did not occur in this case.
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