Failure to Complete Post-Fall Assessments and Notifications
Penalty
Summary
The facility failed to provide necessary care and services to a resident who experienced two falls, as required by federal regulations and the facility's own policies. After the resident was found on the floor on two separate occasions, there was no documented assessment of the resident's change in condition, no neurological assessments, and no post-fall assessments completed. Additionally, the required 72-hour post-fall monitoring and documentation were not performed following either incident. Pain and skin assessments were also missing after the respective falls, and there was no evidence of an interdisciplinary team (IDT) review or update to the resident's care plan. The facility did not notify the resident's physician or the resident's representative after the falls, as mandated by policy. Interviews with nursing staff and the Director of Nursing (DON) confirmed that these notifications and assessments were not completed. The DON and staff provided inconsistent definitions of what constituted a fall, with some initially not considering the incidents as falls due to the resident's behavior of getting up unassisted, despite later acknowledging that being found on the floor should be classified as a fall. Review of the facility's policies indicated clear requirements for post-fall assessment, documentation, and notification, which were not followed in these cases. The lack of proper documentation and follow-up assessments had the potential to delay identification and treatment of possible fall-related injuries and posed a risk for additional falls and injury to the resident. The findings were verified through medical record review and staff interviews, which confirmed the absence of required documentation and follow-up actions after the resident's falls.
Plan Of Correction
F0689 - Free of Accident Hazards/Supervision/Devices Immediate Corrective Action: On 09/23/2025 and 09/25/2025, change of condition, neurocheck, care plan, post fall assessment initiated and MD and responsible party was notified. Residents Affected: On 09/23/2025, the RN Supervisor reviewed all residents with falls to ensure that change of condition, neurochecks, care plan, post fall assessment initiated and MD and responsible party was notified. No other residents were affected. Corrective Action: Licensed nurses were In-serviced by the DON, beginning on September 15th, 2025, on the process for all residents with witnessed or unwitnessed falls. Monitoring of Corrective Action: The DON or their designee will review all witnessed and unwitnessed falls in 24 hours to ensure all steps have been taken. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 Corrective Action: Licensed nurses were In-serviced by the DON, beginning on September 15th, 2025, on the process for all residents with witnessed or unwitnessed falls. Monitoring of Corrective Action: The DON or their designee will review all witnessed and unwitnessed falls in 24 hours to ensure all steps have been taken. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 F0695 - Respiratory/Tracheostomy Care and Suctioning Immediate Corrective Action: On September 19th, 2025, the RN Supervisor changed the tubing for Resident #4's CPAP and properly labeled/stored the tubing.