Failure to Obtain Nursing Assessment Before Moving a Resident After a Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a nurse assessed a resident after a fall before the resident was moved. The resident had dementia, heart failure, severe cognitive impairment, a history of falls, and required moderate assistance for transfers. She was care planned for restorative care due to fall risk and poor safety awareness, and also for a history of physical aggression, with interventions to anticipate needs and remove her from escalating situations. On the morning in question, a nurse aide (NA #1) was providing incontinence care and dressing the resident at the end of the night shift. After moving the resident to the edge of the bed and positioning the wheelchair, NA #1 attempted a “bear hug” transfer without holding the resident’s arms. During the lift, the resident became combative, hitting and yelling, and NA #1 lowered her onto the fall mat beside the bed. NA #1 called for help, and two other aides (NA #2 and NA #3) entered the room and found the resident sitting on the fall mat/floor with her back against the bed. Without first notifying a nurse or obtaining a nursing assessment, NA #2 and NA #3 lifted the resident from the floor/mat into her wheelchair. NA #2 later stated she did not consider the incident a fall based on NA #1’s description and therefore did not notify the nurse before moving the resident. Once the resident was in the wheelchair, the aides removed her nightgown and discovered a large skin tear on her right forearm, and only then did NA #2 seek out the nurse (Nurse #3). Nurse #3 subsequently documented a skin tear to the right forearm, resident-reported pain in the right arm, and that vital signs were within normal limits. The administrator later confirmed that being lowered to the floor should have been considered a fall and that the NAs should have notified a nurse to assess the resident before moving her.
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