Delayed Fall Investigation and Care Plan Update After Resident Fall
Penalty
Summary
A resident with a history of stroke and resulting weakness, who was identified as high risk for falls, was admitted to the facility and required assistance from two staff members and a mechanical lift for transfers. The resident's care plan included interventions such as calling for assistance, keeping the call light within reach, and wearing appropriate footwear. After completing therapy, the resident was left alone in their wheelchair while staff left the room to find additional help for a mechanical lift transfer. During this time, the resident attempted to self-transfer from the wheelchair to the bed and experienced a fall. The facility did not complete the fall investigation in a timely manner, taking over two weeks to finalize the investigation and update the resident's care plan to include assistance back to bed after therapy. Progress notes during this period did not document that the fall was related to being left alone after therapy. Staff interviews confirmed that the investigation and care plan update were not completed within the expected timeframe, resulting in a delay in implementing new interventions to prevent further falls.