Failure to Investigate Falls and Injuries of Unknown Source
Penalty
Summary
The facility failed to ensure thorough investigations were completed for five residents who experienced falls, skin impairments, or injuries of unknown source. In each case, the required incident reports were either not initiated or not completed with sufficient detail to determine the root cause of the incidents or to rule out abuse or neglect. For example, one resident with end stage renal disease and diabetes was observed with multiple skin tears that were not reported or investigated, and there were no treatment orders documented for these injuries. The Director of Nursing was unaware of these injuries until informed during the survey. Another resident with dementia and a history of repeated falls sustained an unwitnessed fall resulting in a head laceration and required emergency care, but the investigation lacked details such as the circumstances leading up to the fall, the resident's activities prior, and witness statements. Similarly, a resident with Parkinson's disease and frequent falls had 17 documented falls, most of which were unwitnessed and not thoroughly investigated to determine if abuse or neglect was involved. The incident reports did not include sufficient information to establish the cause of the falls or whether appropriate interventions were in place. Additional cases included residents with muscle weakness and repeated falls who suffered injuries such as fractures, but the investigations were incomplete, lacking witness statements and comprehensive reviews of the incidents. In all cases, the facility did not follow the required process for prompt and thorough investigation as outlined in state guidelines, resulting in incomplete documentation and failure to rule out abuse or neglect for injuries and falls.