Failure to Investigate and Address Resident Fall Resulting in Injury
Penalty
Summary
The facility failed to provide an environment free from accident hazards and did not ensure adequate supervision to prevent accidents for two residents, specifically focusing on one resident with Alzheimer's disease and severe cognitive impairment. This resident required maximal assistance with activities of daily living and was at high risk for falls, as documented in multiple assessments and care plans. Despite these known risks, the resident experienced a fall that resulted in a major injury, specifically a fractured toe and foot, which required the use of a boot and orthopedic follow-up. Following the incident, the facility did not complete an investigation to determine the causative factors of the fall or the resulting injuries. There was no documentation in the electronic health record or other facility records indicating that an investigation was conducted or that the root cause of the incident was identified. Interviews with administrative and nursing staff confirmed that they could not locate any investigation or related documentation regarding the resident's fractures or the circumstances leading to the injury. The facility's policy required that all fall occurrences be documented and thoroughly investigated using risk management procedures. However, the lack of investigation and documentation after the resident's fall and injury demonstrated a failure to follow this policy. This inaction left the resident at risk for further falls and related injuries, as no interventions or changes to care were implemented based on an analysis of the incident.