Failure to Investigate and Address Resident Falls
Penalty
Summary
The facility failed to conduct a thorough investigation into multiple falls experienced by a resident with diabetes and chronic obstructive pulmonary disease, who was able to communicate needs. The resident had three documented falls within a short period, including one in the bathroom resulting in bruises. Review of the incident investigations revealed that no statements from care staff were collected, no root cause for the falls was identified, and no new interventions or care plan updates were implemented. All investigations were completed 13 days after the first fall, exceeding the expected timeframe. The Director of Nursing Services confirmed that the investigations lacked appropriate witness statements, did not rule out abuse or neglect, and failed to identify or implement measures to reduce further fall risk.