Failure to Conduct Post-Fall Investigation
Penalty
Summary
The facility failed to conduct a post-fall investigation for a resident who was found unresponsive on the bathroom floor following an unwitnessed fall. Medical record review showed that the resident, admitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and schizoaffective disorder, did not have documentation of an investigation into the cause of the fall. Staff interviews with the DON, ED, ADON, and an RN confirmed that no post-fall investigation was completed, despite facility policy requiring staff to investigate falls to determine underlying causes and implement appropriate interventions. This deficiency was identified during a review of three residents for falls, with a facility census of 91 residents.