Failure to Ensure Fall Prevention Alarm Use and Investigation After Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an accident involving a resident and did not implement or document interventions to prevent future falls. Clinical records showed that a physician's order required staff to use a tab alarm for the resident when in bed or chair and to check its function and placement every shift. On the day of the incident, the resident was found on his knees beside the bed after an unwitnessed fall. Staff documentation and witness statements did not indicate that the tab alarm was in place or sounding at the time of the fall, and there was no evidence that the alarm was checked for function or placement during the evening shift until several hours after the incident. Further review revealed that the day shift had documented the alarm as placed and functioning shortly before the end of their shift, but the evening shift did not assess the alarm until late in their shift, well after the fall occurred. There was no documentation at the time of the fall to confirm that the alarm was on or functioning, nor was there evidence of a timely investigation into the circumstances of the fall or the effectiveness of the interventions in place. The deficiency was confirmed during an interview with the Director of Nursing.