Failure to Analyze and Document Fall with Injury
Penalty
Summary
The facility failed to assess and analyze a fall with significant injury for one resident who was identified as a fall risk. The resident had a history of falls, multiple medical diagnoses including anemia, coronary artery disease, hypertension, diabetes, muscle weakness, and peripheral autonomic neuropathy, and required assistance with activities of daily living. The care plan identified the resident as impulsive at times and directed staff to monitor safety, review past falls, determine causes, and educate the resident and family about fall risks. Despite these measures, the resident experienced a fall during therapy, resulting in a cut under the left eye and a head injury that required hospital evaluation. Following the incident, documentation in the medical record indicated that the fall occurred with therapy and resulted in facial injuries, but there was no evidence that a formal fall analysis or root cause investigation was completed. The narrative notes lacked details regarding the circumstances of the fall, contributing factors, or any analysis to determine interventions to prevent recurrence. Interviews with facility staff, including the clinical coordinator and director of nursing, confirmed that required risk management and incident review documents were not completed as per facility policy. The facility's fall prevention and management policy required staff to complete an incident review and analysis after a fall, including clarifying the details of the incident and identifying possible causes. However, in this case, the required documentation and analysis were not performed, and there was no evidence that the effectiveness of interventions was monitored or documented following the fall. This failure to follow established protocols resulted in a deficiency related to the facility's responsibility to assess and analyze accidents to prevent future occurrences.