Failure to Investigate and Report Resident-Reported Fall
Penalty
Summary
The facility failed to comprehensively investigate a reported fall for a resident, as required by its own policy. On the morning in question, a resident with severe cognitive impairment and multiple medical conditions, including end stage renal disease and dependence on dialysis, reported a fall and left arm pain to a Certified Occupational Therapist Assistant (COTA) during a therapy session. The COTA relayed this information to the assigned LPN, who checked the resident and found no visible injury or bruising, then applied lidocaine cream to the resident's dialysis site as ordered. The resident was subsequently sent to a scheduled dialysis appointment. Later that day, the dialysis center contacted the facility to report that the resident had facial bruising and was being transferred to the emergency room for evaluation. Despite the resident's report of a fall and subsequent complaint of pain, the LPN did not initiate the facility's fall protocol, which includes conducting a skin assessment, taking vital signs, notifying the supervisor, DON, physician, and responsible representative, updating the care plan, and starting an incident report. There was also no documentation that the physician or responsible representative was informed at the time the fall was reported. Interviews with facility staff confirmed that the LPN did not follow the required procedures after being informed of the resident's reported fall. The DON acknowledged that the fall investigation protocol was not initiated as required. The facility's policy on assessing falls and their causes was not followed, resulting in a lack of timely investigation and documentation regarding the resident's reported fall and subsequent injury.