Failure to Thoroughly Investigate and Document Fall Interventions
Penalty
Summary
The facility failed to thoroughly investigate falls for a resident with a history of viral hepatitis, anxiety, and arthritis, who was cognitively intact and required partial to moderate assistance for toileting. The resident was identified as being at risk for falls due to muscle weakness and difficulty walking, with interventions such as keeping pathways clear, ensuring the call bell was within reach, using a perimeter mattress, and requiring non-skid socks or shoes. However, after two falls on the same day, the facility's investigations did not document whether these interventions were in place at the time of the incidents. Specifically, the investigations did not confirm if the resident was wearing non-skid socks or shoes during either fall, nor did they verify if a perimeter mattress was present during the second fall. Additionally, the care plan was not updated to reflect all interventions implemented after the falls, such as the addition of a mattress next to the bed. The fall risk assessment did not identify the resident as being at risk for falls, despite the care plan indicating otherwise. The facility's policy required monitoring and documentation of residents' responses to fall interventions, but the investigations lacked evidence that these procedures were followed. Interviews with the DON confirmed these omissions in the fall investigations and care plan documentation.