Failure to Document and Implement Interventions After Resident Falls
Penalty
Summary
The facility failed to ensure proper documentation and implementation of interventions following falls for two residents with significant cognitive impairments and fall risks. For one resident with moderate dementia, diabetes, and atrial fibrillation, multiple falls occurred over a period of several months. The medical record lacked timely documentation of these falls, including missing fall assessments, skin and pain assessments, and progress notes detailing the circumstances of the incidents. In several instances, there was a delay of several days before any interdisciplinary team (IDT) notes were entered, and there was no evidence that new interventions were added to the care plan after repeated falls. Additionally, family notification was not documented for at least one fall. For another resident with Alzheimer's disease and a cognitive communication deficit, an unwitnessed fall was not properly documented in the progress notes, and the change in condition evaluation did not include details about the fall or any interventions to prevent recurrence. The only documentation of the fall was found in a risk management incident report, which was not part of the resident's official medical record and was not visible to all staff. The IDT note, completed several days after the fall, mentioned the resident's shoes were too big and that a new pair would be obtained, but there was no documentation of immediate interventions or assessments in the medical record. Interviews with the LPN and DON revealed that staff were expected to complete fall assessments, skin and pain assessments, and notify the DON, physician, and family immediately after a fall. However, the DON was unaware that the fall risk management assessment and risk management incident reports were not part of the official medical record and not accessible to all staff. The facility's own falls protocol required detailed assessment and documentation after a fall, but this was not consistently followed for the residents reviewed.