Failure to Timely Investigate and Address Falls and Injuries
Penalty
Summary
The facility failed to thoroughly and timely investigate falls and injuries, and did not implement interventions to prevent repeat falls for several residents. For one resident with dementia and multiple comorbidities, there were repeated falls over several months, with delayed or incomplete investigations and unclear or delayed care plan interventions. Incident reports for some falls were completed days after the events, and some investigations were not completed at all. Another resident, also with dementia and mobility issues, experienced multiple falls, including one resulting in a head laceration and another in an occipital hematoma. The facility did not update the care plan with new interventions after one of the falls, and the incident report was completed several days late. Staff interviews confirmed that care plans were not revised and interventions were not implemented in a timely manner following these incidents. Additional deficiencies included a resident who sustained a head injury requiring sutures after falling from bed during repositioning, with the incident not recorded in the facility's logs and the investigation completed late. Another resident suffered a hip dislocation during a transfer, with no documentation of the incident in facility logs and no investigation completed. Staff interviews confirmed that these incidents were not reported or investigated as required.