Failure to Complete Root Cause Analysis and Implement Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure that a root cause analysis was completed and appropriate interventions were implemented following multiple falls experienced by a resident with severe cognitive impairment and a history of falls. The resident, who had diagnoses including a left femur fracture, was found on the floor on several occasions, including an incident where she fractured her hip. Documentation revealed that after these falls, there was a lack of immediate or resident-specific interventions to prevent further incidents, and the care plan was not updated to reflect new strategies addressing the causes of the falls. Progress notes and post-fall evaluations indicated that the resident was found on the floor multiple times, often after attempting to ambulate without her walker or while trying to use the bathroom. Despite these events, the records lacked documentation of why the resident was not using her walker and did not include new interventions to address this behavior. The care plan interventions remained generic and were not revised to address the specific circumstances or root causes of the resident's repeated falls. Interviews with facility staff, including the Assistant Director of Nursing, confirmed that a root cause analysis and new interventions should have been completed and documented after each fall, but this was not done. The facility was unable to provide evidence of interventions implemented after the falls, and interdisciplinary team notes were missing for these incidents. The lack of timely and individualized interventions contributed to the deficiency cited in the report.