Failure to Investigate and Document Resident Falls and Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that falls experienced by residents were thoroughly investigated, properly documented, and that appropriate post-fall assessments and interventions were implemented. In one instance, a resident with dementia, delusional disorder, and Alzheimer's disease experienced an unwitnessed fall and was found on the floor with no documented fall interventions or post-fall evaluation. On a separate occasion, the same resident had another fall, was found with injuries, and was sent to the emergency room, but there was no documentation of a thorough investigation, fall risk assessment, or post-fall evaluation. The Director of Nursing (DON) and the responsible LPN confirmed that required documentation and assessments were not completed, and immediate interventions were not put in place. Additionally, during observation, the resident's call light was not within reach and non-skid strips were missing, contrary to care plan interventions. Another resident, diagnosed with paranoid schizophrenia, dementia, and other conditions, was also found to have experienced an unwitnessed fall. The only immediate intervention documented was a reminder to use the call light, and there was no evidence of a post-fall evaluation being completed. The care plan for this resident included fall risk assessments and environmental safety measures, but these were not followed after the incident. The DON confirmed that the post-fall evaluation was not completed for this resident. Review of the facility's policy indicated that all falls or suspected falls should be considered incidents requiring thorough investigation, documentation, and follow-up. Staff were expected to document specific details in the medical record and initiate accident/incident reports promptly. However, in both cases, the facility did not adhere to its own protocols, resulting in incomplete documentation, lack of timely assessments, and failure to implement or maintain required fall prevention interventions.