Failure to Timely Investigate and Assess Resident Falls
Penalty
Summary
The facility failed to complete timely assessments and thorough investigations following falls for two residents. For one resident with dementia and a history of falls, staff found the individual on the floor with a hip injury and a wet floor due to incontinence. The fall report lacked additional staff interviews and did not reach a conclusion regarding the incident. Staff involved did not complete the fall report or protocol promptly, and no witness statements were collected. The care plan was later revised, but it did not address the correct fall prevention measures, and staff acknowledged the investigation was incomplete. For another resident with Huntington's Disease and moderate cognitive impairment, a fall occurred but the investigation was not completed until several weeks later, and the fall care plan was not updated. Staff confirmed that the investigation was delayed until the resident was being discharged. In both cases, the facility did not follow its own policy requiring timely and thorough investigations, including collecting witness statements and updating care plans after determining the root cause.