Failure to Thoroughly Investigate Unwitnessed Fall with Bruising
Penalty
Summary
The facility failed to conduct a thorough investigation into the cause of an unwitnessed fall with bruising for one resident, as required by its own policy. The resident, who had diagnoses including coronary artery disease, hypertensive heart disease with heart failure, and essential tremors, was cognitively intact, used a wheelchair, and required assistance with personal care. After the resident reported a fall and alleged that two staff members assisted them up, the facility's investigation was limited to a single statement from a nurse who did not provide care to the resident on the date in question. Other staff who worked that evening and provided care were not initially asked to provide statements, and some could not recall the incident or the resident. The Assistant Director of Nursing (ADNS) and Director of Nursing Services (DNS) acknowledged that statements were not collected as required, and the investigation was concluded without comprehensive staff input or clear identification of the cause of the fall. Facility documentation and interviews revealed inconsistencies and gaps in the investigation process. Staff who were present and assigned to the resident on the evening of the fall were not interviewed at the time, and some only provided statements after the fact, indicating they were unaware of the fall or did not observe any injuries. The facility's policy directed continued collection and evaluation of information until the cause of the fall was identified or determined to be unidentifiable, but this process was not followed. The deficiency centers on the facility's failure to respond appropriately to an alleged violation by not completing a thorough and timely investigation as per policy.