Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to conduct a thorough investigation of a fall incident involving a resident, which is a violation of their policy for protection from abuse, neglect, or exploitation. The policy mandates immediate notification and investigation of all alleged violations, including falls, to rule out abuse or neglect. However, there was no documented evidence of an investigation being initiated following the fall of Resident 39, who was found on the floor in his room. This oversight was confirmed during an interview with the Director of Nursing, who was unable to locate an incident report or investigation related to the fall. Resident 39, who has flaccid hemiplegia affecting his left dominant side and is dependent on staff for transfers, was found on the floor between his bed and the window wall. The resident's quarterly Minimum Data Set assessment indicated that he was understood and able to understand others, highlighting the need for careful monitoring and support. Despite the facility's fall management policy requiring a review by an interdisciplinary team and updates to the care plan, there was no evidence that these steps were taken following the incident.
Plan Of Correction
1. Resident 39 who is understood and understands. Upon return demonstration, resident 39 indicated to licensed nursing staff he was sliding from chair and nursing assistant attempted to prevent fall. Resident 39 signed statement indicating he was sliding from chair and nursing assistant was attempting to prevent a fall. 2. A review of incident reports for past two weeks will be reviewed to ensure a thorough investigation was completed. 3. The Interdisciplinary team will review with report of falls during morning clinical meeting to determine if further information is needed to complete fall investigation. The Director of Nursing/designee will re-educate licensed nursing staff including agency nurses on the fall management process including completion of report/investigation at time of fall. 4. To maintain and monitor compliance, a weekly audit will be conducted by the Director of Nursing or designee for four weeks to make sure the incidents of falls have incident report or investigation. Results of this audit will be reviewed by the Quality Assurance and Improvement Committee for additional recommendations if necessary.