Failure to Conduct Timely and Thorough Investigation After Resident Fall
Penalty
Summary
The facility failed to ensure a complete and thorough investigation was conducted to rule out neglect following a resident's unwitnessed fall. According to the facility's policy, investigations must include timely review of documentation, interviews with all relevant staff across shifts, and comprehensive documentation. In this case, the resident, who had severe cognitive impairment due to dementia, was found face down on the floor in front of her bed by a nurse aide. The incident was not immediately or thoroughly investigated, as key staff statements were delayed by up to thirteen days, and not all relevant staff, such as the overnight nurse and nurse aide, were interviewed promptly or at all regarding the resident's condition after the fall. Additionally, there was a lack of documentation in the resident's clinical record between the time of the fall and her subsequent transfer to the emergency room the following day. The investigation did not include statements from staff who provided care during the overnight and morning shifts, nor was there documentation of the resident's condition during this period. The Director of Nursing confirmed that the investigation was neither complete, thorough, nor timely, and that the facility did not follow its own policy for investigating alleged neglect.