Failure to Investigate and Accurately Report Resident Fall
Penalty
Summary
A resident with dementia, permanent vision loss, and difficulty walking was admitted to the facility and had a care plan noting poor safety awareness and impulse control. On the day of the incident, the resident was left unattended in a bathroom by a CNA who left to obtain an incontinent brief. During this time, the resident fell and sustained a superficial laceration to the back of the head. The CNA returned, found the resident on the floor, placed the resident in a wheelchair, and misrepresented the location of the fall to the supervisor, stating it occurred in the dining room. The facility did not thoroughly investigate the true circumstances and location of the fall until 12 days after the event, despite conflicting reports and documentation. The LPN who documented the incident did not assess the resident post-fall, as she was on break and relied on information from the RN supervisor. The actual details of the incident were only clarified during a multidisciplinary care conference, revealing the CNA's misrepresentation and the resident being left unattended. The findings were confirmed with the DON and reviewed during the exit conference with facility leadership.