Failure to Accurately Assess, Investigate, and Monitor Resident After Fall
Penalty
Summary
A resident with a history of Parkinson's Disease, muscle weakness, dementia, and previous falls was not provided with adequate care and services to prevent accidents. The resident's fall risk assessment was found to be incomplete and inaccurate, as it only marked the age category and failed to account for significant risk factors such as vision impairment, cognitive deficits, use of antihypertensive medication, unsteady gait, and altered awareness. The Director of Nursing (DON) acknowledged that these omissions placed the resident at a high risk for falls. Additionally, the resident's Minimum Data Set (MDS) did not accurately reflect the level of assistance required for activities of daily living (ADLs), as therapy certifications indicated the need for moderate to contact guard assistance, while the MDS documented independence in these activities. The facility also failed to conduct a thorough investigation following the resident's fall. The investigation did not include an interview with the resident's roommate, who had witnessed the fall and could provide critical details about the incident. The DON admitted to forgetting to interview the roommate, which was contrary to facility policy requiring clarification of fall circumstances and evaluation of events leading up to the fall. Furthermore, the resident's care plan was not resident-centered and lacked specific, individualized interventions to address the resident's risk for decline in ADLs and falls, as required by facility policy. There were additional lapses in monitoring and documentation after the suspected fall. The responsible party reported the fall to both the LVN and the DON, but the LVN did not initiate further assessment or monitoring because the resident denied the fall. Progress notes revealed gaps in monitoring and documentation across several shifts following the incident, despite facility policies mandating ongoing monitoring and documentation of residents after a fall. These deficiencies in assessment, investigation, care planning, and post-fall monitoring contributed to the failure to ensure a safe environment and adequate supervision to prevent accidents.