Failure to Investigate and Document Falls with Immediate Interventions
Penalty
Summary
The facility failed to ensure that falls were thoroughly investigated to determine a root cause, were properly documented in the medical record, and that immediate and appropriate interventions were implemented. This deficiency affected three residents who were reviewed for falls. For one resident with severe cognitive impairment and multiple risk factors for falls, there were repeated incidents where the resident was found on the floor in various locations, including the dining room, activity room, and their own room. In several instances, there was no documentation of immediate interventions following the falls, and interventions such as non-skid socks were repeatedly implemented despite already being in place. There was also no evidence of a root cause analysis or thorough investigation for any of the falls during the review period. Another resident with severe cognitive impairment and a history of falls had multiple falls for which there was no nursing documentation or fall follow-up notes completed. The care plan for this resident included numerous interventions for fall prevention, but the medical record lacked documentation for some falls and did not include thorough investigations or root cause analyses for any of the falls that occurred during the review period. A third resident, who was cognitively intact but at high risk for falls due to cervical spine issues and weakness, experienced falls while attempting to transfer or ambulate. Immediate interventions were inconsistently documented, and in at least one instance, there was no documentation of an intervention following a fall. Interviews with facility leadership confirmed the lack of immediate interventions, duplicate interventions, and the absence of thorough investigations or root cause analyses for the falls. Facility policy required immediate interventions, thorough documentation, and root cause analysis for incidents such as falls, but these procedures were not followed.