Failure to Complete Root-Cause Analysis After Multiple Resident Falls
Penalty
Summary
The facility failed to complete a root-cause analysis after a resident experienced three falls within a four-day period, beginning within 48 hours of admission. The resident had severe cognitive impairment, vision and hearing difficulties, and required staff assistance for ambulation, toileting, and other activities of daily living. The care plan identified a risk for injury related to falls, with a history of falls and generalized weakness. Despite these known risks, the facility did not conduct a root-cause analysis to determine if there was a common factor contributing to the repeated falls. Incident reports documented that the resident's falls were unwitnessed and occurred in her room, often after attempting to transfer or ambulate without assistance and without using the call light. The resident was found on the floor multiple times, sometimes with minor injuries, and was noted to be disoriented and confused at the time of the incidents. Although staff implemented some interventions after each fall, such as posting reminder signs and increasing visual checks, the facility did not follow its own policy requiring evaluation of falls to determine appropriate interventions to prevent future occurrences.