Failure to Thoroughly Investigate Unsupervised Fall During Smoking
Penalty
Summary
The facility failed to thoroughly investigate a fall involving a resident who was cognitively intact and required supervision while smoking. The resident's care plan and smoking assessment both indicated that staff supervision was necessary during smoking due to cognitive impairment and inability to safely smoke or access the smoking area independently. On the day of the incident, a nursing assistant (NAC) assisted the resident outside to smoke but left the resident unattended to use the restroom. During this time, the resident dropped a lit cigarette, leaned forward from the wheelchair to retrieve it, and subsequently fell, hitting her head on the concrete. The facility's fall investigation inaccurately documented the incident as a witnessed fall, despite statements from the resident and staff indicating the resident was left alone at the time. Interviews with the resident, a collateral contact, and staff confirmed the resident was unsupervised when the fall occurred. The Director of Nursing acknowledged discrepancies in the investigation documentation and agreed that the witness statement could have been more detailed. The failure to accurately investigate and document the circumstances of the fall resulted in a deficiency under WAC 388-97-0640 (6)(a)(b).