Failure to Document and Investigate Resident Fall Incident
Penalty
Summary
A resident with diagnoses including asthma, osteoarthritis, and anxiety, who was cognitively intact and required staff assistance for activities of daily living, was found sitting on the floor of their room. The incident was initially reported by the resident's relative, who received a call from the resident stating they were on the floor, naked, and needed help. Facility staff, including a Registered Nurse Supervisor and floor nurses, responded and found the resident alert but disoriented, expressing confusion about their surroundings and alleging rape. Subsequent medical assessment found no injuries or changes in the resident's baseline condition. Despite facility policy requiring documentation and investigation of all accidents and incidents, there was no documented evidence that an incident/accident report or investigation was completed for the resident's fall. Interviews with facility staff confirmed that while the incident was verbally reported to supervisory staff and medical providers, no written report or investigation could be located. The Administrator stated that the allegation of rape took precedence over the fall, resulting in the lack of documentation for the accident as required by policy.