Failure to Investigate and Document Multiple Resident Falls
Penalty
Summary
The facility failed to investigate or determine the root causes for three separate falls experienced by a resident with a history of cardiac arrest and moderate cognitive impairment. Despite the facility's policy requiring immediate investigation and documentation of all incidents and accidents, there was no evidence of completed fall investigations or incident reports for falls that occurred on 1/12/25, 2/13/25, and 2/25/25. Progress notes documented the falls, including one witnessed by a CNA where the resident slid to the floor while using a stand lift, another where the resident was found on the floor after complaining of dizziness, and a third involving an unwitnessed fall resulting in a head injury. However, the required Fall Evaluation Tool was not completed for these incidents. Interviews with the resident confirmed she recalled falling three times, and interviews with the DON revealed a lack of awareness regarding two of the falls and an admission that an incident report was not completed for the third due to being sidetracked. The DON acknowledged that each fall should have been separately investigated and documented, as per facility policy, to identify causes and implement preventive interventions. The absence of investigations and documentation for these falls constituted a failure to ensure the area was free from accident hazards and that adequate supervision and follow-up were provided to prevent accidents.