Failure to Document and Monitor Resident After Fall
Penalty
Summary
The facility failed to completely and accurately document the assessment and monitoring of a resident after a fall. A resident, who was moderately cognitively impaired and had diagnoses including hypertension, overactive bladder, and weakness, experienced a fall while attempting to transfer from her bed to her wheelchair. The fall was witnessed by a family member, who notified staff. Nursing progress notes indicated that the fall was reported to the NP, DON, Administrator, and POA, but the resident's record lacked further documentation related to the assessment, monitoring, and follow-up of the fall event. Interviews with facility staff revealed that standard protocol required a Fall Event to be documented in the computer system, including specifics about the fall, immediate interventions, and an IDT review to determine root cause and update the care plan as necessary. The Physical Therapist, who reviews daily fall reports generated from documented Fall Events, was unaware of the incident due to the absence of such documentation. The facility's Fall Management Policy also required immediate assessment, initiation of a Fall Event, IDT review, and care plan updates, none of which were fully documented for this incident.