Incomplete and Inaccurate Post-Fall Investigation
Penalty
Summary
The facility failed to ensure that post-fall investigations were accurate and complete for a resident with multiple sclerosis, muscle weakness, and type II diabetes, who was at risk for falls. The resident's care plan included interventions such as bilateral assist bars and encouragement to use the call light for transfers. The resident experienced a fall in her room, which was documented as witnessed by an RN, who reported seeing the resident lose balance and slide to the floor while transferring from bed to wheelchair. The RN completed a post-fall assessment and educated the resident on using the call button, but the fall investigation only included a single witness statement from the RN. However, interviews with the resident and a CNA revealed inconsistencies in the account of the fall. The resident stated her door was closed and no staff were present at the time of the fall, and that she waited on the floor for staff to find her. The CNA reported finding the resident on the floor with the door closed and stated the fall was unwitnessed, contradicting the RN's account. The CNA did not provide a witness statement for the investigation. The facility's fall risk management policy required obtaining statements from all staff in the area, but this was not followed, resulting in an incomplete and inaccurate investigation.