Failure to Assess and Document Incidents for Cognitively Impaired Resident
Penalty
Summary
The facility failed to complete proper assessments following incidents involving a resident with severe cognitive impairment, aphasia, schizophrenia, and a history of multiple falls. The resident was known to frequently lower herself to the floor, sometimes requiring assistance to get up, and had poor safety awareness and spatial judgment. Despite repeated incidents where the resident was found on the floor, staff did not consistently complete incident reports or assessments unless the event was unwitnessed, and sometimes did not notify the nurse when the resident was found on the floor. On one occasion, the resident was found with significant bruising to her right foot and hip, but due to her condition, staff were unable to obtain a description of what had occurred. Staff interviews revealed a pattern of not reporting or assessing incidents when the resident was observed lowering herself to the floor, as this was considered typical behavior for her. The facility's policy required documentation and assessment of all accidents and incidents, including details such as the nature of the injury, circumstances, witness accounts, and notifications. However, these procedures were not consistently followed for this resident, resulting in a failure to ensure all incidents were properly assessed and reviewed as required by facility policy.