Failure to Investigate and Address Causes of Resident Falls
Penalty
Summary
The facility failed to determine the causes or contributing factors for multiple falls experienced by a resident, and did not revise the resident's plan of care or facility practices to reduce the likelihood of further falls. The resident, who had a history of repeated falls from both bed and wheelchair, sustained a fractured clavicle as a result of one of these incidents. Progress notes documented several falls over a period of time, including incidents where the resident slid out of bed, was found on the floor next to the bed, was found on the floor in the dining room (resulting in an emergency room visit for shoulder pain), and was found sitting on the floor in the hallway. Review of post-fall documentation revealed that for each of these falls, there was either no post-fall review completed or no description of what occurred and no root cause identified. The facility's policy required completion of a post-fall assessment, incident report, care plan review, and documentation of all assessments and actions following a fall. However, interviews and record reviews confirmed that these steps were not followed for the resident's falls, and no interventions were identified or implemented to prevent further incidents.