Incomplete Fall Investigations and Lack of Root-Cause Analysis
Penalty
Summary
The facility failed to ensure that fall investigations were complete and thorough, including the completion of root-cause analysis (RCA), for three out of five sampled residents. The facility's own policies required licensed nurses to perform timely assessments, complete detailed fall investigation forms, and document all relevant information in the resident's clinical record after each fall. However, for the residents reviewed, incident/accident reports and medical records were missing critical information such as nurse notes, progress notes, and detailed descriptions of the falls. In several cases, the investigation forms lacked explanations of behavioral concerns, contributing diagnoses, and did not include RCAs. One resident with fibromyalgia and restless leg syndrome experienced two non-injury falls, but the investigation forms did not provide sufficient detail, and no RCA was completed. Additionally, a required positioning bar intervention was not in place during observation, and there was no documentation in the resident's chart related to the falls. Another resident, identified as being at risk for falls due to gait and balance problems, had a fall that was not reflected in the care plan, and the incident report lacked a detailed behavioral assessment and RCA. Similarly, a third resident with Parkinsonism and ataxic gait had a fall that was not documented in the care plan, and the incident report did not include an RCA or a nurse note in the chart. Interviews with staff, including CNAs, LPNs, and the DON, revealed inconsistencies in the completion of fall investigations, documentation, and care plan updates. Staff acknowledged that incident reports were often incomplete, RCAs were not documented, and care plans were not consistently updated after falls. The DON confirmed that there was no specific place on the incident report to document the RCA and that RCAs were shared verbally rather than documented. These actions and omissions resulted in the facility's failure to maintain thorough and complete fall investigations as required by policy.