Failure to Complete and Document Required Post-Fall Assessment
Penalty
Summary
Facility staff failed to meet professional standards of care by not completing and documenting a fall assessment as required by facility policy after an unwitnessed fall involving one resident. The facility’s Event Investigation policy directed staff to complete a Report of Event Form as soon as possible for unexpected events such as falls, and to document the event location and type, vital signs, mental/neurological status, range of motion, and pain assessment. The resident’s admission MDS showed moderate cognitive impairment and a history of two or more non-injury falls since admission. Video footage from the resident’s room showed a CNA entering the room twice with the resident’s lower body on the fall mat/mattress next to the bed. The CNA reported to the nurse on two occasions that the resident was on the fall mat/mattress. The EMR for the date of the incident did not contain documentation that the LPN completed a Report of Event Form or performed and documented the required post-fall assessments, including neurological status and range of motion. The LPN stated that the CNA reported the unwitnessed fall but the LPN was busy and did not immediately assess the resident, and that approximately 10 minutes later the resident’s family arrived and assisted the resident back to bed. The LPN did not enter the room until after the family left over an hour later, at which time the resident was asleep; the LPN obtained vital signs but did not initiate neurological or range of motion checks and only believed a progress note had been documented. The administrator and DON both stated they expected completion of an event form, vital signs, neurological checks, range of motion, pain assessment, and documentation per policy for an unwitnessed fall. The resident’s responsible party reported arriving, assisting the resident from the fall mat/mattress to bed, remaining for about an hour and a half, and not seeing any staff enter the room or assess the resident during that time.
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