Failure to Conduct Root Cause Analysis and Update Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure a root cause analysis was conducted and appropriate interventions were implemented for a resident with a history of falls. The resident, who had moderately impaired cognition and diagnoses including paranoid schizophrenia, required substantial assistance for toileting and partial assistance for transfers. Despite being identified as high risk for falls due to intermittent confusion, recent falls, and being chair bound, the facility did not document a root cause for the falls or update the care plan with new interventions after two unwitnessed falls. On two separate occasions, the resident was found on the floor in their room, once while reaching for shoes and another time after attempting to use the bathroom. In both instances, documentation failed to indicate whether the resident had appropriate footwear, and the fall assessment forms lacked analysis of contributing factors or evidence that the care plan and treatment sheet were reviewed or revised. Observations showed the resident was assisted by staff with transfers and footwear, but staff interviews revealed a lack of awareness regarding specific fall prevention interventions for the resident. Interviews with nursing staff and the DON confirmed that risk management forms were either not completed or not accessible, and there was no evidence that a root cause analysis or new interventions were determined following the falls. The facility's policy required reassessment and review of the safety plan after any fall, but this process was not followed, resulting in a failure to address the resident's ongoing fall risk.