Failure to Investigate Falls and Update Care Plans After Multiple Incidents
Penalty
Summary
Surveyors identified that the facility failed to ensure areas were free from accident hazards and did not provide adequate supervision to prevent accidents for multiple residents with a history of falls and cognitive impairment. Three residents with moderate cognitive impairment and significant medical conditions, including dementia, encephalopathy, osteoarthritis, diabetes, and hemiplegia, experienced multiple unwitnessed falls. Despite these incidents, the facility did not conduct thorough fall investigations to identify root causes or update the residents' care plans with new interventions to prevent further falls. The review of medical records revealed that after each fall, the facility did not consistently complete required neurological checks as outlined in their Fall Checklist. For several falls, neuro checks were missing or incomplete, and in some cases, the checks were performed at incorrect intervals. Additionally, the facility lacked a formal falls policy and relied on an undated Fall Checklist, which was not consistently followed by staff. The Director of Nursing confirmed that fall investigations did not identify root causes, care plans were not updated, and neuro checks were not thoroughly completed following unwitnessed falls. For one resident, five falls occurred over a two-week period without any new safety interventions being added to the care plan. Another resident experienced six falls, including incidents resulting in injury and hospital transfer, yet no new interventions were implemented, and one fall was not investigated at all. The facility's failure to follow fall procedures, update care plans, and complete post-fall assessments contributed to the deficiency identified by surveyors.