Failure to Investigate and Analyze Resident Fall Incident
Penalty
Summary
The facility failed to complete an investigation, including a root cause analysis, after a resident experienced a fall while being loaded into a facility van. The resident, who had diagnoses of hypertension, transient ischemic attack, and chronic kidney disease, was documented as having impaired mobility and required substantial staff assistance for transfers and ambulation. On the day of the incident, the resident was being assisted by a licensed nurse and the activity director, but did not have foot pedals on her wheelchair, which made it more difficult to push her. As the staff attempted to pull the resident up the ramp, she slid forward out of the wheelchair and onto the ramp, resulting in two small skin tears on her left elbow. The incident was documented in the nurse's note, and the resident was treated for her injuries. Despite the fall and resulting injury, the electronic medical record lacked documentation that an investigation or root cause analysis was completed for the incident. Interviews with staff confirmed that a full investigation was not conducted, and administrative staff acknowledged the absence of a root cause analysis. The facility's policy required that investigations begin immediately and include a root cause analysis, but this was not followed in this case. The failure to investigate the fall and analyze its causes constituted a deficiency in responding appropriately to an alleged violation.