Failure to Assess and Document Resident After Fall
Penalty
Summary
The facility failed to evaluate and analyze hazards and risks, and did not assess a resident following a documented fall. According to the facility's fall policy, when a fall occurs, an incident and accident report should be completed, documentation should be initiated and continued for at least three days, a fall investigation and supervisor report should be completed, and the care plan should be updated. For one resident with a history of falls and diagnoses including Paranoid Schizophrenia, muscle weakness, and altered mental status, a fall was documented in the progress notes. However, there was no evidence of an incident report, follow-up monitoring, or required documentation related to this fall. Interviews with staff revealed confusion and lack of recall regarding the incident, with the LPN and staffing coordinator both unable to remember the fall or confirm that it was reported. The DON confirmed that protocol required assessment and documentation after a fall, but was unable to provide any documentation for the incident in question. The administrator also could not locate any incident report or related documentation, despite the fall being noted in the resident's progress notes. The resident was described as cognitively intact at the time of the incident.