Failure to Thoroughly Investigate Resident Fall with Major Injury
Penalty
Summary
The facility failed to thoroughly investigate a fall with major injury involving a resident who was at medium risk for falls and had significant medical conditions, including a prior femur fracture, heart failure, and severe cognitive impairment. The resident, who was dependent on staff for transfers and required a Hoyer lift, experienced an unwitnessed fall during the night and was found on the floor with abrasions. The resident reported confusion at the time of the fall and was subsequently diagnosed at the hospital with a closed fracture of the distal end of the left femur. The facility's investigation into the incident was incomplete, lacking written witness statements, documentation of interventions in place at the time of the fall, records of the last time the resident was seen or toileted, and other required details. The facility's fall management policy required a thorough post-fall assessment, documentation of all actions, and collection of witness statements in the case of injury, but these steps were not fully carried out in this case.