Failure to Conduct Timely IDT Meeting After Resident Fall
Penalty
Summary
The facility failed to ensure that an interdisciplinary team (IDT) meeting was conducted in a timely manner following a resident's fall, as required by the facility's own policy and procedure. The resident, who had diagnoses including atrial fibrillation, congestive heart failure, and type 2 diabetes, experienced a fall after attempting to steady herself on a wheelchair that was out of reach while exiting the bathroom. The resident's care plan identified her as having poor balance, an unsteady gait, and poor safety awareness, with interventions such as keeping the call light within reach and frequent visual checks. After the fall, staff physically assessed the resident and completed documentation, but there was no documented evidence that an IDT meeting occurred within the required 72-hour timeframe to investigate the incident and determine causative factors. Interviews with staff, including an LVN, the Assistant Director of Nursing, and the Director of Nursing, confirmed that facility policy mandates an IDT meeting within 72 hours of a fall to review the event, conduct a root cause analysis, and implement interventions to prevent future incidents. However, the review of the resident's electronic medical record did not show that such a meeting took place after the fall. The facility's Fall Management Program policy specifically requires the IDT-Falls Committee to meet and document their findings and actions within this timeframe, but this protocol was not followed in this case.