Failure to Thoroughly Investigate Resident Falls
Penalty
Summary
The facility failed to thoroughly investigate falls for two residents, resulting in incomplete fall investigations. For one resident with diabetes, heart disease, and other chronic conditions, a fall occurred when her incontinence brief slid down during a transfer, causing her to trip. Although she was assessed and found to have no injuries, the facility's fall investigation lacked witness statements, a root cause analysis, documentation of when she was last toileted, evidence of call light use, and implementation of new interventions. The care plan had identified her as a fall risk, but the investigation did not meet the facility's policy requirements. Another resident with Alzheimer's disease and multiple comorbidities experienced a fall resulting in a head laceration and required emergency treatment. The investigation for this incident also lacked staff witness statements, a root cause analysis, documentation of toileting or call light use, and evidence of new interventions. The DON confirmed that these elements were missing from both investigations, and the facility's policy required such steps to be completed for all falls, especially unwitnessed ones. These deficiencies were confirmed through record review, interviews, and policy review.