Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident who was found unresponsive on the floor by a nurse after the resident’s roommate alerted staff. The nurse responded immediately, assessed the resident at the scene, and called 911. The resident was unable to answer questions and was transferred to the hospital by EMS. Documentation included a progress note, incident report, and EMS paperwork, but no further investigation was conducted regarding the circumstances of the fall. Interviews with the nurse, DON, and administrator confirmed that no additional steps were taken to investigate the incident, such as interviewing the roommate or other staff, or gathering further evidence about the fall. The facility’s own policies require investigation and documentation of the circumstances surrounding falls and incidents, but these procedures were not followed in this case.