Delayed Nursing Response and Assessment After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide prompt care and services following a fall for one resident reviewed for quality of care. The resident, who had dementia, severely impaired cognition (BIMS 3/15), impaired vision, and multiple fall risk factors including Alzheimer’s disease, impaired safety awareness, arthritis, hypertension, and a history of stroke, had a known history of falls, self-transferring, urinating, and disrobing in common areas. The care plan identified the resident as at risk for falls and documented behaviors such as bending down to pick items up from the floor and going to hands and knees, and included an intervention to assist the resident to the floor if they asked to sit on the floor. The CNA Kardex indicated that when the resident demonstrated less ability to walk, staff should use a wheelchair. On the date of the fall, the resident was observed on video transferring themself back and forth between different chairs in a common area while a CNA monitored. At one point, the resident missed the arm of a chair and went to the floor. A progress note documented that at the time of the fall the resident had one shoe and one non-slip sock on. Staff interviews indicated that the resident typically wandered from chair to chair and might fall asleep in a chair when winding down. The fall occurred during the evening shift change, and a CNA at the scene attempted to get the resident up but encountered resistance from the resident. Following the fall, the CNA called toward the nurse station to alert nurses that the resident was on the floor. An LPN reported hearing the CNA say the resident was on the floor, turned and saw the resident on the floor playing with their feet, and felt the resident was safe, so continued working on computer documentation. The LPN stated that two nurses at the nurse station reacted similarly and did not immediately respond. Another CNA reported that the CNA at the scene requested assistance, including asking for two male staff to help, but the nurses “just looked” at the CNA and did not come right away. The administrator’s review of the video showed that nurses did not immediately get up to assess the resident, and approximately 15 minutes elapsed between the time of the fall and the nurses’ response, contrary to facility policies requiring immediate assistance and assessment after an incident or accident.
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