Failure to Conduct Thorough Investigation After Resident Fall
Penalty
Summary
The facility failed to follow its Accidents and Incidents - Investigating and Reporting policy by not conducting a thorough investigation after a resident was found on the floor following a fire alarm. The resident, who had severe cognitive impairment, significant mobility limitations, and multiple medical diagnoses including atrial flutter and diabetes, was found unresponsive with low blood oxygen and blood pressure, requiring emergency transport. Documentation showed that the fall was unwitnessed, and only one witness statement was collected, despite several staff being present on the unit at the time of the incident. Interviews with other staff members who were on duty revealed that they were not interviewed or asked to provide statements regarding the incident. The facility was unable to provide additional witness statements or documentation about the circumstances of the fall. The Director of Nursing and the Administrator determined the fall was cardiac in origin after reviewing hospital records, but the facility did not complete a comprehensive investigation as required by policy, which mandates prompt initiation and documentation of investigations, including collecting witness accounts and other pertinent data.