Failure to Conduct Thorough Fall Investigations and Assessments
Penalty
Summary
The facility failed to conduct thorough and complete investigations for multiple residents who experienced falls. For several residents with complex medical histories and high fall risk, incident reports and investigations were incomplete. Specifically, documentation was missing regarding environmental factors such as room clutter, wheelchair safety, and whether residents had their needs met or received timely assistance prior to the falls. In some cases, there was no information about when the last assistance was provided or if care plan interventions, such as toileting schedules, were followed. Incident reports for residents who sustained injuries from falls did not consistently include required assessments. For example, neurological assessments were initiated but not documented, and skin assessments for injuries were not completed or lacked details such as measurements and descriptions. Environmental assessments were often left blank, failing to identify potential causes like wet floors, inappropriate footwear, or room hazards. Additionally, there was a lack of documentation regarding whether staff assessed blood sugar levels for residents with diabetes after a fall, as required by their care plans. Interviews with staff, including the DON and regional clinical leadership, confirmed that incident reports and investigations were not thorough and did not meet facility policy expectations. Staff acknowledged that important sections of the incident reports were left incomplete, and necessary assessments were not performed or documented. These deficiencies were observed for multiple residents, including those with a history of falls, complex medical needs, and those dependent on staff for transfers and toileting.