Failure to Complete Accurate and Thorough Fall Investigation
Penalty
Summary
The facility failed to ensure an accurate and thorough fall investigation was completed for a resident with significant medical needs, including Parkinson's disease, dementia, muscle weakness, and dependence on staff for activities of daily living. The resident was found on the floor with lacerations and abnormal vital signs, including tachycardia and hypoxia, and was subsequently transferred to a hospital. Documentation and interviews revealed discrepancies in the reported time of the fall and when emergency medical services (EMS) were contacted. The facility's records indicated the fall occurred at approximately 3:00 A.M., while the EMS report showed a call was placed before midnight, and staff reported the resident had been assisted back to bed prior to EMS arrival. The facility's fall investigation did not reconcile these conflicting time frames, and staff were unable to provide an explanation for the discrepancies. The facility's policy required a thorough interdisciplinary review of falls, including assessment of causal factors and environmental review, but the investigation lacked clarity and completeness regarding the circumstances and timing of the incident. This deficiency affected the resident's care and did not meet the facility's own standards for fall prevention and management.