Failure to Thoroughly Investigate Unwitnessed Fall in Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with multiple medical conditions, including chronic obstructive pulmonary disease, diabetes, depression, anxiety, and chronic kidney disease, experienced an unwitnessed fall during the night. The resident, who used supplemental oxygen at night and was moderately cognitively impaired, was found sitting on the floor next to her recliner with a skin tear on her right upper arm. Documentation indicated she was incontinent at the time of the fall and attempted to change her bedding herself, but the fall report did not reflect this incontinence. The report also lacked details regarding whether staff assisted the resident with changing her bedding or clothing, if she was assisted back to bed, the time she was last seen before the fall, whether her call light was within reach, if she was wearing oxygen or if the tubing contributed to the fall, the suspected cause of the skin tear, any treatment provided for the injury, and whether she was a candidate for a nighttime toileting schedule. The facility's policy required thorough investigation and documentation of all incidents, including injuries of unknown source, and mandated reporting and analysis to prevent recurrence. However, the fall report was incomplete and did not provide sufficient information to rule out potential abuse or neglect or to analyze what changes could have been made to prevent future incidents. The administrator acknowledged that the report lacked necessary details and that the fall was not thoroughly investigated, as expected by facility policy.