Failure to Initiate Fall Protocol After Suspected Resident Fall
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident identified as high risk for falls. The resident, an elderly female with muscle wasting and impaired mobility, had a history of falls and was on a care plan that included fall prevention interventions such as a low bed and fall mat. During a survey, the resident reported to the surveyor that she thought she had fallen the previous night, but was unsure if she had reported it to staff. The resident was observed to be alert, oriented, and without visible injuries at the time. Upon being notified by the surveyor of the suspected fall, the DON interviewed the resident, who stated the fall might have occurred in a dream. The DON did not initiate the facility's fall protocol, did not treat the event as an unwitnessed fall, and did not perform physical or neurological assessments. There was no documentation of a fall assessment, neuro checks, or incident report for the suspected fall in the resident's clinical records or progress notes for the relevant dates. Facility policy required that any fall, whether witnessed, reported, or presumed, be assessed, documented, and followed by appropriate notifications and interventions, including neuro checks for unwitnessed falls. The DON acknowledged in interviews that she did not follow these protocols after being informed of the suspected fall, and that this failure could place residents at risk for unidentified injuries and other complications.