Failure to Investigate and Address Causes of Repeated Resident Falls
Penalty
Summary
The facility failed to thoroughly investigate and identify the causes of repeated falls for a resident with significant cognitive impairment and multiple medical diagnoses, including Alzheimer's disease, dementia, and kidney failure. The resident experienced multiple falls from bed, all occurring during late evening or early morning hours, and was consistently found incontinent of bowel and bladder at the time of each fall. Despite documentation of interventions such as a low bed and, later, bed mats, there was no evidence that staff tracked or documented when the resident was last toileted or provided incontinence care prior to the falls. The post-fall evaluations did not include information about the timing of incontinence care, and staff interviews confirmed the absence of a system to monitor or record toileting assistance for the resident. The care plan included interventions for fall prevention, such as keeping the bed in the lowest position, using a perimeter mattress, and scheduled toileting, but these measures were not consistently documented as being in place at the time of each fall. Staff acknowledged that the falls occurred close to the night shift and that the existing toileting schedule would not have prevented many of the incidents. The facility's policy required identification of risk factors and thorough post-fall investigations, including determining the last time the resident was seen or toileted, but these steps were not followed. As a result, the underlying causes of the falls were not adequately addressed, and appropriate interventions were not implemented in a timely manner.