Failure to Investigate and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to thoroughly investigate and conduct a root cause analysis of a fall incident involving a resident with severe cognitive impairment, dementia, and a history of falls. The resident, who was admitted with multiple diagnoses including unsteady gait and schizoaffective disorder, experienced several falls and an accident resulting in injury. Despite these incidents, the facility did not consistently implement or document fall prevention interventions as recommended in the resident's care plan. Observations showed the resident frequently wore non-skid socks instead of shoes, even after an intervention specifying the need for proper footwear was added to the care plan following a previous injury. A review of the resident's medical record and incident reports revealed multiple falls and accidents, including one where the resident fell out of bed and sustained a laceration to the head, requiring hospital transfer. However, the facility did not provide an incident or investigation report for this event, and there was no evidence of immediate interventions or a thorough investigation following the incident. Interviews with staff, including the LPN, unit manager, and DON, indicated a lack of awareness and follow-up regarding the fall, with the DON confirming they were not notified of the event and no investigation report was completed. The facility's own policy requires staff to report, investigate, and review all incidents and accidents, including conducting root cause analyses and implementing immediate interventions. Despite this, the required documentation and follow-up were not completed for the resident's fall on 3/9/25, and the intervention for proper footwear was not consistently implemented, as evidenced by multiple observations of the resident without shoes. This failure to follow policy and ensure consistent implementation of fall prevention measures contributed to the deficiency.