Failure to Thoroughly Investigate Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident with dementia, muscle weakness, lack of coordination, and a history of repeated falls. The resident was admitted with severe cognitive impairment and was dependent on staff for activities of daily living. On the date of the incident, the resident fell in the dining room, resulting in a laceration to the left forehead and subsequent transfer to the emergency room for evaluation and treatment. Review of the facility's incident reporting log and investigation documentation revealed that witness statements were missing from the investigation of the fall. Interviews with staff confirmed that witness statements were not obtained or could not be located for the incident. Staff members described the expected procedure of reporting and documenting incidents, including the completion of witness statement forms by all staff present. However, it was acknowledged by both the Resident Case Manager and the Administrator that the required witness statements were not included in the investigation file for this incident. This lack of documentation indicated that the facility did not complete a thorough investigation as required.