Failure to Supervise, Assess, and Document After Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s environment was free from accident hazards and that adequate supervision and assessment were provided to prevent and respond to accidents. The resident was admitted with diagnoses including cerebral atherosclerosis, unspecified dementia with severe cognitive impairment, encephalopathy, dysphagia, and essential hypertension, and was care planned as being at risk for falls due to weakness, incontinence, psychotropic medication use, and dementia. The care plan interventions included staff assistance with transfers, keeping the call light within reach, positioning the right side of the bed against the wall, and frequent staff checks. A fall risk evaluation also identified the resident as being at risk for falls. Video footage showed that late at night the resident fell from the left side of the bed onto her knees on a fall mat between the bed and dresser, then repositioned herself to a seated position and was heard moaning. Several hours later, the same footage showed the resident lying directly on the floor on her left side with a pillow and blankets placed behind her. No staff were observed entering the room throughout the night shift to check on the resident between the time of the fall and the early morning. When an RN eventually entered the room to administer medications, he did not verbally assess the resident before moving her, but instead positioned himself behind her, placed his hands under her armpits, lifted her from the floor, and placed her back in bed while the resident moaned. The RN briefly asked what happened and if she had injuries but did not allow time for a response before stating she had none, and proceeded to administer medications. Review of the medical record revealed no nursing documentation of the fall, no post-fall assessment, and no evidence that the physician was notified at the time of the incident. The facility’s post-fall investigation, initiated after the family reported the fall and provided video footage, confirmed that staff did not enter the resident’s room to check on her throughout the night shift, that the RN did not complete any assessment prior to transferring the resident from the floor to the bed, and that no post-fall assessment or required fall follow-up documentation was completed. The facility’s falls policy required that unwitnessed falls have neurological checks initiated and that fall follow-up documentation, fall risk evaluation, and skin and pain assessments be completed after a fall, which did not occur in this case.
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