Failure to Report and Document Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to implement proper protocol following a resident fall. Record review showed that a resident with severe cognitive impairment and a history of impaired mobility and generalized weakness was not reported as having fallen, despite a care plan identifying fall risk. The resident's roommate reported witnessing the fall and stated that it took staff some time to respond, and that she informed both staff and administration about the incident. However, there was no documentation of the fall in the resident's records, and the fall risk assessment did not reflect any recent falls. Interviews with staff, including the nurse on duty and the DON, revealed that they were unaware of the fall and had not received any reports about it. The DON confirmed that staff are required to report falls in writing, but no such report was found. The lack of documentation and follow-up after the fall indicates that the facility did not ensure adequate supervision or accident reporting as required by protocol.