Failure to Prevent and Investigate Resident Falls
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for multiple residents. Several residents with significant cognitive and physical impairments experienced falls that were not thoroughly investigated, and care plans were not consistently followed or updated to reflect their needs. In multiple instances, required interventions such as low bed positioning, fall mats, and accessible call lights were not in place at the time of the falls, despite being documented in the residents' care plans. One resident with severe cognitive impairment and a history of falls was found on the floor in a wet environment, having removed their incontinence brief, with the bed in the lowest position but the floor mat only partially in place. The investigation did not include staff statements to determine when the resident was last checked or if all interventions were in place, and the root cause of the fall was not determined. Another fall for the same resident occurred while the resident was reaching for a call light that was not accessible, and again, the investigation lacked staff statements and a clear root cause analysis. A second resident, who was dependent on staff for transfers and had a history of bilateral leg amputation, fell from bed during care by two aides. The bed was found in a high position and the fall mat was not in place, contrary to the care plan. The investigation did not include complete witness statements, did not address the bed height, and did not document neurological checks after the resident sustained a closed head injury. A third resident, with multiple comorbidities and mobility impairments, fell from a wheelchair after returning from dialysis. The fall investigation was incomplete, lacking documentation of mental status, predisposing factors, staff statements, and a thorough root cause analysis. The care plan was not updated to reflect the need for increased monitoring or specific interventions after the fall, and there was no documentation of when the resident was last seen prior to the incident.