Failure to Report, Investigate, and Care Plan for Resident Falls
Penalty
Summary
The facility failed to ensure that resident falls were properly reported, investigated, and that individualized fall care plans were in place for all residents reviewed for falls. Four residents with significant cognitive and physical impairments experienced multiple falls, yet their incidents were not consistently documented or investigated according to facility policy. In several cases, there was no evidence of incident reports or investigations following falls, and fall interventions were either missing from care plans or not supported by physician orders. One resident with Alzheimer's disease and muscle weakness experienced several falls, including sliding out of bed and a chair, but not all incidents were reported or investigated, and interventions such as a pull string tab alarm, low bed, and fall mat were not included in the care plan or physician orders. Another resident with severe cognitive impairment and physical limitations had a care plan that identified fall risk but lacked specific interventions, and a fall incident was not reported or investigated. A third resident with dementia and impaired cognition experienced a fall with no subsequent care plan or investigation, and no fall interventions were ordered by a physician. A fourth resident with Huntington's disease and a history of repeated falls was found on the floor after rolling out of bed and later fell from a specialized chair, but there was no evidence of fall investigations or care plans addressing fall risk. Staff interviews confirmed these deficiencies, and a review of facility policy indicated that falls should be investigated and care plans updated, which was not consistently done for these residents.