Failure to Conduct Thorough Post-Fall Investigation
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to conduct a thorough investigation following an incident involving a resident who was found fallen in their room, face down and with their head positioned between the bedside table and bed. The resident was identified as being severely cognitively impaired, and fall risk precautions such as a low bed and floor mat were in place, with the call light within reach at the time of the incident. Documentation of the incident investigation did not include a root cause analysis or indicate whether additional interventions were necessary. The Chief Nursing Officer confirmed that the investigation should have addressed the root cause of the fall and ruled out abuse or neglect, but this was not completed as required.