Failure to Complete Required Post-Fall Evaluations and IDT Review
Penalty
Summary
The facility failed to conduct an Interdisciplinary Team (IDT) meeting, a fall risk evaluation, and a post-fall evaluation for a resident following an unwitnessed fall. The resident, who had diagnoses including cognitive communication deficit, anxiety, and dementia, was noted to have severely impaired cognition and was dependent on staff for all activities of daily living. After the resident experienced an unwitnessed fall and sustained a skin tear, staff did not complete the required fall risk evaluation or post-fall evaluation, nor did they convene an IDT meeting as outlined in facility policy. Interviews with nursing staff and the Director of Nursing confirmed that the necessary assessments and team review were not performed after the fall. The facility's policy required a new fall risk evaluation, a post-fall evaluation, and an IDT review with documentation following any fall. The absence of these actions was acknowledged by staff and leadership, and it was noted that these steps are intended to identify risk factors and update the care plan to prevent further incidents.