Failure to Prevent and Investigate Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance to prevent accidents and did not conduct a thorough investigation following a resident's fall. The resident, who had a history of cervical laminectomy, Parkinson's disease, diabetes, and recent vertigo, fell out of bed after a CNA left the room to assist another resident. The resident was unable to reach the call light and, after calling for help without response, used the phone to call 911. Law enforcement and EMS responded, assisted the resident, and transported them to the emergency department for evaluation. The facility's policies required staff to identify interventions based on resident-specific risks and to conduct a root cause analysis within 24 hours of a fall, including documentation of the circumstances, assessment data, and interviews. However, the event report for the incident lacked nursing documentation, staff or resident interviews, and a root cause analysis. There was also no documentation of the resident's condition immediately after the fall, including the status of the surgical neck wound or a description of the initial fall after returning from the bathroom. Interviews with facility staff confirmed that the investigation was incomplete and did not include the required elements. The DON could not recall the root cause analysis or the reason for the fall, and the event report was closed without these critical components. The resident's medical record and event report did not meet the facility's own policy requirements for post-fall assessment and documentation.