Failure to Investigate Resident's Alleged Fall
Penalty
Summary
The facility failed to conduct a complete and thorough investigation into a resident's reported fall. The resident, who had multiple diagnoses including hypertension, cerebral infarction, arthritis, a history of falling, diabetes, schizophrenia, and substance abuse, informed nursing staff that she had fallen the previous week, slipping on water near her bed while attempting to walk to her wheelchair and hitting her head. She reported pain to the right side of her head, and the physician was notified with orders for x-rays. However, there was no documentation in the clinical record of any falls for the entire month, and the Assistant Director of Nursing confirmed that no investigation was initiated into the resident's allegation as reported to staff.