Failure to Investigate Resident Fall and Update Care Plan
Penalty
Summary
The facility failed to investigate a fall experienced by a resident with a history of repeated falls and spinal stenosis, who also had some cognitive impairment as indicated by a BIMS score below 10. The resident was able to answer surveyor questions appropriately during the survey. According to progress notes, the resident fell in the hallway while pushing a wheelchair, and the fall was unwitnessed. The resident was transferred to the hospital per physician's request, with no observable injuries except for redness on areas impacted by the fall. The resident reported having had four falls at the facility, with the most recent occurring in the bathroom with staff present but unable to prevent the fall. The resident recalled a fall in June but could not remember exact dates. Interviews with facility staff revealed that the restorative nurse and DON, who oversee the falls program, were only aware of two falls, not the third fall documented in the progress notes. The restorative nurse stated that fall investigations are conducted and care plans updated with interventions after each fall, but was unaware of the third fall until reviewing the notes during the survey. The DON confirmed that the agency LPN who documented the fall did not notify either the DON or the restorative nurse about the incident, and described the LPN as substandard and no longer permitted to work at the facility. Facility policy requires fall risk assessments and investigations after each fall, with interventions to be added to the care plan, but this process was not followed for the resident's fall on the specified date.