Failure to Convene and Document IDT Falls Committee After Resident Falls
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) Falls Committee met to review and document findings and interventions after a resident experienced two falls. The resident, who was admitted with diagnoses including type 2 diabetes mellitus, muscle weakness, and schizophrenia, required substantial to maximal assistance for several activities of daily living. According to facility records, the resident fell on two separate occasions while in the facility, both times reportedly after falling asleep in a wheelchair. Despite the facility's policy requiring the IDT-Falls Committee to meet within 72 hours of a fall to review the event, conduct a root cause analysis, and document interventions, there was no documentation in the resident's medical record indicating that such meetings occurred after either fall. The Director of Nursing confirmed that the required IDT meetings were not held or documented following these incidents, as evidenced by the absence of relevant entries in the progress notes or IDT assessment forms.