Failure to Investigate and Report Resident Fall
Penalty
Summary
The facility failed to conduct a fall investigation, develop a root cause, and implement relevant fall interventions for one resident who was at high risk for falls. The resident had multiple diagnoses, including cellulitis of the right lower limb, chronic pain, lack of coordination, and required assistance with personal care. The resident was documented as not cognitively intact and required supervision or touching assistance with walking. The care plan identified impaired cognitive function and high fall risk, with interventions to cue, reorient, and supervise as needed. Despite these risk factors, the facility did not report the resident's fall in a timely manner, and the incident was only recognized after a coroner's request from the hospital following the resident's death. Interviews revealed confusion and lack of communication among facility staff regarding the reporting and investigation of the fall. The Administrator stated that the fall was not reported until after the coroner's inquest, and the DON and ADON each believed the other was responsible for reporting and follow-up. The facility's policy required that all incidents or accidents be reported, assessed, and investigated by nursing staff and reviewed by the Administrator and DON, but this process was not followed in this case. The failure to promptly report, investigate, and address the fall resulted in a lack of timely interventions for the resident.