Failure to Report, Assess, and Prevent Resident Falls
Penalty
Summary
The facility failed to ensure timely reporting, assessment, and investigation of resident falls, as well as implementation of fall prevention interventions according to resident care plans. For one resident with multiple comorbidities including dementia, chronic pain, and impaired balance, video footage showed the resident on the floor beside her bed, with a CNA attempting to lift her back onto the bed without reporting the fall to a nurse. The resident was wearing socks, which contributed to difficulty in the transfer. The incident was not reported by staff, and the facility's investigation was incomplete, lacking a statement from the involved CNA and unable to determine the circumstances due to delayed reporting. The facility's policy required staff to evaluate and document falls, and for nurses to assess and document injuries and circumstances, which was not followed in this case. Another resident with hemiplegia, weakness, and impaired balance was found in bed with the bed in the highest position and without a required fall mat on one side, contrary to the care plan interventions. Staff were unsure about the need for fall mats on both sides and confirmed the absence of the mat. These failures affected two of three residents reviewed for falls and demonstrate noncompliance with accident hazard prevention and supervision requirements.