Failure to Prevent Accidents and Inadequate Fall Investigations
Penalty
Summary
The facility failed to ensure that six residents received adequate supervision and assistance devices to prevent accidents, as required by policy. Multiple incidents were not thoroughly investigated, and root causes were not determined, which led to missed opportunities for implementing effective interventions. For example, one resident with dementia and a high fall risk experienced multiple falls, including one resulting in a hip fracture. After being observed ambulating alone, no additional interventions were implemented, and the resident was not assessed by an RN prior to being placed in a wheelchair post-fall, despite RN availability. The facility's investigations into these falls did not include comprehensive root cause analyses. Another resident fell from a wheelchair, but the investigation did not address how the resident was seated, whether the resident was interviewed, or why the fall care plan was not developed until months later. Additionally, the resident was not transferred according to the established plan of care at the time of the fall. In another case, a resident-to-resident altercation was not investigated, and no revisions were made to the care plan following the incident. The facility also failed to investigate how a resident rolled out of bed multiple times despite interventions such as body pillows, and did not consistently determine the root cause of these falls. Further deficiencies included a resident who experienced multiple unwitnessed falls, with investigations failing to determine if previous interventions were in place or to identify root causes. The resident's wander alert bracelet was also improperly placed. Another resident's fall interventions, such as a fall mat and body pillows, were not in place or were incorrectly positioned at the time of a fall, and care plan updates were delayed. In several cases, care planned interventions, such as toileting schedules, were not followed, and falls were not thoroughly investigated to ensure interventions were in place. These failures resulted in actual harm for one resident and the potential for more than minimal harm for others.