Failure to Thoroughly Investigate Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to ensure adequate supervision and assistance to prevent accidents for a resident with a history of falls and multiple medical conditions, including congestive heart failure, kidney failure, diabetes mellitus, muscle weakness, and abnormal gait. The resident, who was cognitively intact and required supervision and assistance for transfers and mobility, experienced an unwitnessed fall in their room. The resident was found on the floor between the bed and the wall, with a minor injury to the right finger, and reported attempting to ambulate but could not recall if an assistive device was used at the time. The facility's policy required thorough investigation and documentation of all incidents and accidents, including falls, with specific instructions for staff to complete incident reports, document all pertinent information, and identify root causes. However, the fall investigation packet for this incident was incomplete, with missing information such as the date and time of the fall, staff present or who found the resident, and details about the resident's activities and interventions prior to the fall. Statements from involved CNAs were either missing or inadequately completed, with many questions left blank or marked as not applicable, and no statement was obtained from the CNA assigned to the resident at the time of the fall. Interviews with facility staff confirmed that the expected protocol was not followed, as all areas of the fall packet should have been thoroughly completed. The Director of Nursing acknowledged that the investigation was not thorough. The lack of a complete and thorough investigation meant that key information about the circumstances of the fall and the effectiveness of fall prevention interventions was not obtained.