Failure to Investigate and Document Resident Falls
Penalty
Summary
The facility failed to thoroughly investigate falls that resulted in injuries for four out of ten residents reviewed for accidents. The facility's policy required immediate and comprehensive documentation of occurrences, including witness statements, details of the incident, and a root cause analysis, but these steps were not consistently followed. For each resident, the documentation lacked pertinent details such as the circumstances of the fall, staff and resident interviews, and whether care plan interventions were in place or effective at the time of the incident. One resident with severe cognitive impairment and a history of falls experienced multiple unwitnessed falls, including one resulting in a subdural hematoma and hospitalization. The investigation reports for these incidents did not document the resident's activity at the time of the fall, staff interviews, or a root cause analysis. Another resident, also with significant cognitive impairment and a history of falls, suffered a fracture after falling from bed. The investigation into this fall did not include sufficient details about the circumstances, staff interviews, or an evaluation of the effectiveness of existing interventions. Additional cases included a resident with muscle weakness and a history of falls who was found on the floor with head and arm injuries, and another resident who sustained a head and wrist injury after a fall. In both cases, the documentation failed to include staff or resident interviews, a root cause analysis, or a timely and thorough investigation. The DON and other staff confirmed that the required investigative steps were not completed, and the lack of detailed documentation prevented evaluation of whether interventions were effective in preventing further falls.