Failure to Complete Post-Fall Assessments, Notifications, and Care Plan Updates
Penalty
Summary
The facility failed to follow its own policy and accepted standards of practice regarding post-fall care and documentation for three residents. Staff did not accurately complete post-fall observation reports for 72 hours, as required, by failing to obtain and document current vital signs for two residents and not completing post-fall observations for the full 72 hours for another resident. Additionally, there was a failure to document a fall in the nurse progress notes for one resident, and neuro checks were not completed for an unwitnessed fall as required by protocol. The facility also did not ensure timely notification of the physician and emergency contact when a resident experienced a fall. In one instance, after a resident was assisted to the floor by a CNA during a transfer, there was no documentation of physician or emergency contact notification. Furthermore, the care plans for two residents were not updated in a timely manner following their falls, and for another resident, the care plan was not updated at all after the incident. In several cases, interventions related to falls were not implemented or documented promptly. The residents involved had various medical conditions, including diabetes, malnutrition, syncope, muscle weakness, and cognitive communication deficits. At the time of the deficiencies, residents experienced falls that were either unwitnessed or involved injury, such as bruising, lacerations, and pain. Despite these incidents, required assessments, monitoring, and documentation were either incomplete or not performed according to facility policy, as evidenced by missing or outdated vital signs, lack of neuro checks, and incomplete progress notes.