Failure to Investigate and Document Resident Falls Resulting in Fracture
Penalty
Summary
The facility failed to thoroughly and accurately investigate two falls experienced by a resident with moderate cognitive impairment, resulting in a left hip fracture that required hospitalization and surgery. The resident, who had diagnoses including dementia, schizophrenia, and difficulty walking, experienced two falls on the same day. Documentation of both incidents was incomplete, with missing entries for pain assessment, level of consciousness, mental status, and mobility. The incident reports lacked essential details, such as staff involved, witness statements, and accurate timing, and there was no comprehensive summary or root-cause analysis to determine how the falls led to the fracture. Direct care staff, including CNAs assigned to the resident, were not interviewed or asked to provide statements at the time of the incidents. The DON considered the nurse's incident report as the only required statement and did not obtain additional narratives from other staff. The investigation process was inconsistent, with the DON unable to identify which CNAs were assigned to the resident and no summary of the investigation available. The facility's fall program and incident reporting policies were not followed, as evidenced by the lack of risk analysis, monitoring for pain or neurological changes, and implementation of interventions to prevent further injury. Additionally, the facility did not report the incident as required by its abuse and neglect policy, despite the resident sustaining a serious injury of unknown origin. The documentation was further compromised by altered dates and times on post-fall forms, and the DON admitted that certain documentation was omitted if no abnormal findings were observed. The lack of a thorough investigation and failure to follow established protocols resulted in an incomplete response to a significant injury event.