Failure to Conduct Post-Fall Assessments and Implement Interventions
Penalty
Summary
The facility failed to follow its own policies and procedures regarding post-fall assessments, injury identification, incident investigation, and implementation of interventions for two residents who experienced falls. In one case, a resident with severe cognitive impairment and multiple medical conditions was found on the floor after an unwitnessed fall. The nursing staff did not conduct a full body assessment prior to moving the resident, and neurological checks were not performed as required by policy. Documentation was incomplete, with missing records of pain assessments, medication administration, and timely notification of the resident's power of attorney and physician. The care plan was not updated promptly to reflect new interventions for skin integrity or fall prevention, and pain management orders from the hospital were not reconciled in the medical record. In another instance, a resident with a history of behavioral issues and recent hospitalization for sepsis experienced a change of plane, interpreted by staff as intentional behavior rather than a fall. As a result, no post-fall assessment, risk management incident report, or follow-up assessments were conducted. The physician and family were not notified, and the event was not documented in the resident's record. Staff interviews revealed a lack of awareness and understanding of the need to document and investigate such incidents, regardless of perceived intent. The facility's investigation into these incidents was limited to direct care staff interviews and did not include a thorough root cause analysis. Staff were not informed of new interventions implemented after the falls, and there was a lack of communication regarding changes to care plans. The deficiencies identified include failure to provide adequate supervision, failure to assess and document post-fall injuries, failure to notify responsible parties, and failure to update care plans and implement interventions to prevent further incidents.