Failure to Thoroughly Investigate Resident Fall Incident
Penalty
Summary
The facility failed to thoroughly investigate a fall incident involving a resident with severe cognitive impairment and dementia. The resident, who was on a blood thinner, experienced a fall resulting in a hematoma and nasal fracture. The investigation report did not include interviews with key individuals such as the social services director who initially reported the fall, the resident's representative who was present at the time, or other staff who had contact with the resident during the incident. There were also conflicting statements regarding the resident's cognitive status and insufficient documentation of how the fall was discovered and managed. The facility's policy requires that all reports of abuse, neglect, or injuries of unknown origin be thoroughly investigated, including interviews with the person reporting the incident, the resident or their representative, staff on all shifts, and documentation of the investigation. However, the investigation into this incident lacked interviews from the social worker who reported the fall and the resident's representative, despite both being directly involved or present. The investigation also failed to clarify how the social worker became aware of the fall and did not include statements from all relevant staff. Staff interviews revealed uncertainty about the reporting process and the thoroughness of the investigation. The DON and other staff acknowledged that interviews with the social worker and the resident's representative would be expected, but these were not conducted. The investigation report contained inconsistencies and did not fully comply with the facility's own policy for abuse and neglect investigations, leading to an incomplete assessment of the incident.