Failure to Evaluate Falls and Follow Care Plan Interventions
Penalty
Summary
The facility failed to ensure that falls were properly evaluated and that care plan interventions were followed for two residents. One resident, admitted with heart failure, slid out of bed and sustained a skin tear, after which there was no documentation indicating whether the fall was witnessed or unwitnessed, nor evidence that the fall was evaluated or that care plan interventions were reviewed. The resident was sent to the hospital at their request and did not return. Another resident, admitted with failure to thrive, experienced an unwitnessed fall, but the fall investigation was incomplete, lacking analysis and documentation to show the incident was evaluated or that care plan interventions were followed. This resident had a history of previous falls in the facility. Facility staff confirmed that thorough and complete analyses were not conducted for either incident.