Incomplete Investigation Following Resident Fall
Penalty
Summary
The facility failed to ensure a thorough investigation was completed following a fall involving a resident with multiple diagnoses, including diabetes mellitus, end stage renal disease, and benign neoplasm of the duodenum. The resident, who was cognitively intact but required maximal assistance with transfers and had upper extremity impairments, experienced a witnessed fall while attempting to transfer independently from bed to chair, despite prior instructions to seek assistance. The accident/incident report for this event was incomplete, lacking an investigative summary and staff statements, and there was no documentation that the resident's representative was notified of the fall. According to facility policy, an investigation should be initiated for any outward event, such as a fall, and should include staff interviews and statements from those present during the incident. However, the Registered Nurse who witnessed the fall did not complete the required incident report or obtain statements from Certified Nurse Aides, citing short staffing and multiple responsibilities as reasons. The only documentation provided was a progress note, and the Assistant Director of Nursing confirmed that only the top portion of the report was completed, with no explanation for the omission.