Inadequate Fall Investigation and Documentation
Penalty
Summary
The facility failed to maintain proper documentation and conduct thorough investigations for a resident who experienced repeated falls. The surveyor reviewed incident reports for falls that occurred on three separate occasions. The reports lacked essential details such as statements from witnesses, vital signs, and whether the falls were witnessed or unwitnessed. The facility's policy required these elements to be included in the incident reports, but they were missing in the cases reviewed. The resident involved had a history of repeated falls and was admitted with diagnoses including cardiomegaly and hypomagnesemia. The resident's cognitive status was severely impaired, as indicated by a low score on the Brief Interview for Mental Status (BIMS). Despite these conditions, the incident reports did not include comprehensive assessments or documentation of the resident's condition following the falls, such as vital signs or any potential injuries. Interviews with facility staff, including CNAs, LPNs, and the Director of Nursing, revealed inconsistencies in the documentation process. Staff confirmed that statements from witnesses and detailed assessments were not consistently obtained or recorded. The Director of Nursing acknowledged the deficiencies in the incident reports and confirmed that the facility's policy was not followed, as the reports lacked signatures, titles, and complete information about the incidents.
Plan Of Correction
Plan of Correction F610 Level D Completion Date: 1/15/2025 Corrective Action: Resident #347 incident report dated 26 was reviewed and reinvestigated by Nursing Administration. Statements were obtained by nursing staff involved in care of resident during incident. Post incident follow up was rewritten. ID Other Residents: Any resident within the facility who has an incident that requires an investigation. Systemic Change: In-service How to Complete a Thorough Investigation to the Nursing Department by Nursing Administration by 1/15/2025. In-service What to Include in an Incident Report: to the Nursing Department by Nursing Administration by 1/15/2025. Statements will be obtained for all unwitnessed incidents by those individuals who interacted with resident within the timeframe of the incident. Monitoring: Audit - Incident Reports and Investigations will be completed on the following schedule: (4) weekly xos 2 weeks then (4) monthly xs 2 months then (4) quarterly x 1 quarter by Nursing Administration by 1/15/2025. Results of the audits will be brought to QA/QAPI on a quarterly basis xs 3 quarters.