Failure to Conduct Thorough Accident Investigation
Penalty
Summary
Facility staff failed to conduct a thorough investigation following an accident involving a resident with severe intellectual disabilities who was found on the floor of their room with a hematoma and a laceration over the left eyebrow, accompanied by significant bleeding. The resident reported getting up to walk to the bathroom and falling, resulting in head trauma. Staff provided immediate care, including applying ice and a pressure dressing, and the resident was sent to the hospital. Upon review, it was found that the facility's assessment of the incident did not include interviews with staff or the resident's roommate, which limited the ability to determine the root cause of the fall. The assessment only noted the resident's alertness, periods of forgetfulness, impaired memory, and gait imbalance, and concluded that ambulating without assistance was a predisposing factor. The lack of comprehensive investigation denied staff the opportunity to fully evaluate the causes of this and potential future accidents.