Incomplete Investigation of Resident Fall Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident involving a resident, identified as Resident R24, who was admitted with diagnoses including high blood pressure, dislocation of the right shoulder joint, and diabetes. On a specific date, Resident R24 was turned on her side with the assistance of one person, left unattended, and subsequently fell out of bed. The facility did not provide evidence of post-fall monitoring as required, and the resident was found unresponsive the following day, ceasing to breathe at 5:41 a.m. The investigation into the incident was incomplete, as the facility did not obtain signed and dated statements from witnesses, including the resident's roommate and the LPN assigned to her care during the relevant time period. The facility's policy on 'Abuse Investigation and Reporting' requires that incidents or suspected incidents of abuse, mistreatment, neglect, or injury of unknown source be thoroughly investigated, including obtaining written witness reports. However, in this case, the facility did not adhere to its policy, as confirmed by the Nursing Home Administrator during an interview. The lack of a complete investigation and failure to obtain necessary witness statements meant that the incident was not fully investigated to rule out abuse or neglect, leading to a deficiency in compliance with regulatory requirements.
Plan Of Correction
Resident R24 was no longer in the facility to complete an assessment and interview to rule out abuse or neglect. Other residents who sustained a fall within the one week prior to the fall sustained by Resident R24 will be interviewed by the Director of Nursing (DON)/designee to determine the cause of the fall and rule out abuse or neglect. Nursing staff will be educated by the DON on the need to immediately initiate an investigation as to the reason for a resident's fall in order to rule out abuse or neglect. The education will include the details of completing a proper investigation including a physical assessment of the resident for injury, an interview with the resident to glean the possible cause of the fall, an assessment of resident's surroundings at the time of the fall, and interviews with obtained statements with the roommate, other residents, and all staff working in the area at the time of the fall in order to rule out abuse or neglect. Audits will be completed of all resident falls 2 weeks prior to Resident R24's fall to ensure an investigation was completed as the cause of the fall to rule out abuse or neglect. All future falls will be reviewed at the weekly falls committee to ensure a complete investigation as to the reason of the fall was completed in order to rule out abuse or neglect. The results of the education and audits will be shared at the monthly QAPI meeting for review and approval.