Failure to Follow Post-Fall Procedures and Documentation
Penalty
Summary
The facility failed to follow its own Falls Management policy after a resident experienced a fall while being transferred with a sit-to-stand lift. According to the facility's policy, a complete head-to-toe assessment, vital signs, physician and family notification, and documentation of these actions are required after any fall. For the incident in question, there was no documentation of a post-fall assessment, vital signs, or notifications to the physician or family in the resident's medical record. The progress notes did not mention the fall or any follow-up, and the required documentation was missing from both the progress notes and risk management records. The resident involved had a history of multiple falls, confusion, and weakness, and was identified as being at risk for falls with interventions added to the care plan after previous incidents. Staff confirmed that the resident fell out of the lift, and interviews with the DON and Facility Administrator verified that the required post-fall procedures and documentation were not completed. The deficiency was identified through record review and staff interviews, which confirmed that the facility's policy was not followed for this resident's fall.