Failure to Investigate and Address Causes of Multiple Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and thorough investigation of falls for a resident with a history of multiple unwitnessed falls. The resident, who had severe cognitive impairment, incontinence, and multiple diagnoses including dementia and psychosis, experienced three unwitnessed falls. Each fall was not thoroughly investigated to determine the root cause, and interventions were not promptly or appropriately updated to address the underlying issues. For example, after a fall related to toileting needs, the care plan was not revised to increase toileting assistance until two months later. Documentation and post-fall assessments lacked critical information, such as the resident's incontinence status at the time of each fall, the timing of the last toileting, and whether the resident had the capacity to use a call light for assistance. In one instance, the intervention implemented was to provide a different type of call light, despite staff interviews indicating the resident did not use the call light intentionally. Additionally, there was confusion and lack of clarity in documentation regarding the use of assistive devices, such as whether a walker or wheelchair was in use at the time of a fall. Interdisciplinary team meetings were held after each fall, but the interventions developed were not always based on a thorough root cause analysis. The facility's own policy required systematic identification, evaluation, and analysis of hazards and risks, as well as timely implementation and communication of interventions. However, the investigation and documentation following each fall did not consistently meet these standards, resulting in missed opportunities to prevent further incidents.