Failure to Investigate and Care Plan After Resident Fall
Penalty
Summary
The facility failed to administer and use its resources effectively and efficiently for one resident, as evidenced by the lack of a thorough investigation and care planning following a significant incident. Staff interviews, clinical record reviews, and policy examination revealed that after a resident was found lying on the floor in their bedroom/adjoining bathroom, no individualized care plan was developed or implemented to address bowel incontinence, toileting needs, staff supervision, or assistance with transfers. The facility's policy required a comprehensive investigation of all incidents and accidents, including consultation with the medical director and development of a care plan by the interdisciplinary team to ensure a safe environment. However, administrative staff confirmed that these steps were not taken for this resident. Further, the medical director reported that the resident was sent to the emergency room and diagnosed with an acute large intraparenchymal hemorrhage and hydrocephalus, with a history of cerebral amyloid angiopathy and prior intracranial hemorrhages. Despite the facility's policy mandating a completed investigation and review by the DON, and consultation with the medical director, staff interviews confirmed that a complete and thorough investigation was not conducted or recorded. The administrative staff did not utilize available resources, including medical director consultation, to identify the root cause of the fall and ensure a safe environment, resulting in a deficiency.