Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to conduct an investigation following a fall experienced by a resident with a history of hemiplegia and hemiparesis after a cerebral infarction, who also had moderate cognitive impairment. The incident occurred when the resident dropped herself to the floor while staff were opening the door for medics, after which she was transported to the hospital. Review of facility records, including the State Incident Reporting log and progress notes, revealed that there was no investigation documented for this fall, nor was the incident logged as required. Interviews with nursing staff confirmed that standard protocol following a fall includes assessment, notification, obtaining staff statements, and completing an incident report in the computer system. However, the Director of Nursing acknowledged that no incident report was completed and the event was not entered into the reporting log. The lack of investigation meant that the root cause and contributing factors of the fall were not identified, and there was no documentation to rule out abuse, as required by state guidelines.