Failure to Timely Investigate Resident Falls
Penalty
Summary
The facility failed to ensure timely investigation of resident falls, as evidenced by the lack of documented fall investigations for two residents. One resident with diagnoses including convulsions, dementia, and bipolar disorder experienced an unwitnessed fall and was found on the floor next to the bed, unable to describe the incident, and was subsequently sent to the hospital. The medical record for this resident did not contain any documentation of a fall investigation or interdisciplinary team (IDT) review for the incident, which was confirmed by the Assistant Director of Nursing (ADON). Another resident, with a history of end-stage renal disease, cerebral infarction, and type 2 diabetes mellitus, was identified as being at moderate risk for falls and had moderately impaired cognition. This resident experienced two falls: one while attempting to go to the restroom and another while waiting for transportation, the latter resulting in a laceration and scalp injury requiring hospital transfer. The facility delayed the investigation of the first fall and failed to complete an investigation for the second fall, as confirmed by an LPN. Facility policy required that possible causes of falls be identified within 24 hours, but this was not followed in these cases.