Failure to Thoroughly and Timely Investigate Resident Falls
Penalty
Summary
The facility failed to ensure that falls were thoroughly and timely investigated for two residents who were identified as being at risk for falls. One resident with chronic diastolic heart failure, vascular dementia, a history of left femur fracture, and osteoporosis experienced a fall while attempting to transfer herself from bed to chair. The resident, who had moderately impaired cognition and was dependent on staff for transfers, was found on the floor by an LPN after calling for help. The post-fall evaluation was not completed, and the facility's fall investigation only included a brief statement from the LPN and hospital records, lacking details about interventions in place at the time of the fall or the circumstances leading up to the incident. Another resident, who had intact cognition and was moderately at risk for falls, was found on the floor after an unwitnessed fall from bed. The resident sustained a facial injury, scalp laceration, and abrasions, and was transferred to the hospital, where he later passed away. The facility's documentation did not include a progress note about the fall, and the fall investigation was not completed until over a month later. The investigation only included a brief statement from an LPN and did not provide information about interventions in place or the events leading up to the fall. Interviews with the DON confirmed that thorough investigations were not completed for either resident following their falls. The DON also stated that there was no established timeline for completing fall investigations and that immediate interventions were limited to sending the residents to the hospital. The facility's policy required interdisciplinary review and timely investigation of all falls, including assessment of interventions and environmental factors, but these steps were not documented or completed in these cases.