Failure to Thoroughly Investigate Resident Fall and Identify Root Cause
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident with severe cognitive impairment who requires supervision and assistance while ambulating. The resident, who uses a wheelchair and wheeled walker, attempted to get dressed and access her closet without staff assistance, resulting in a fall that caused a head injury requiring stitches and a splint for her left arm. At the time of the incident, staff were present in the hallway, and a CNA witnessed the resident walking unaided and falling but was unable to intervene in time. The resident was not using her walker and it was unclear if she was wearing appropriate footwear. The facility's fall investigation did not identify the root cause of the fall, as required by policy. The incident report lacked documentation regarding the resident's footwear and whether the walker was in use, both of which are critical factors in determining appropriate post-fall interventions. The DON confirmed that the investigation relied solely on a written statement from the CNA and did not include an interview or comprehensive assessment of the circumstances surrounding the fall. As a result, the facility did not ensure that all relevant information was gathered to inform effective interventions to prevent future accidents.