Untimely Completion of Fall Investigation
Penalty
Summary
The facility failed to complete a timely investigation following a fall incident involving a resident with a history of respiratory failure, hemiplegia, and hemiparesis after a stroke. The resident, who was able to communicate needs, reported falling out of their wheelchair while attempting to return to bed. The incident occurred on 06/19/2025, but the documentation of interventions, investigation summary, and conclusion were not completed until 06/26/2025, which was seven days after the fall. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, confirmed that the investigation should have been completed within five days, as per facility policy and regulatory guidelines. Both staff members acknowledged that the investigation did not meet the expected timeline. The delay in completing the investigation was attributed to factors such as weekends, but it was recognized that the process exceeded the required timeframe.