Failure to Investigate and Prevent Resident Falls
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards and did not provide adequate supervision and interventions to prevent accidents for three residents. Multiple falls occurred among these residents, some resulting in injuries such as a head laceration and a fracture, yet the facility did not conduct thorough root cause investigations or implement new safety interventions after each incident. In several cases, care plans were not updated following falls, and there was a lack of documentation regarding post-fall assessments, monitoring of injuries, and interdisciplinary team (IDT) reviews as required by facility policy. One resident with severe cognitive impairment and significant physical assistance needs experienced an unwitnessed fall resulting in a head laceration and was transferred to the emergency room. There was no documentation of a root cause investigation, no new interventions were implemented, and the care plan was not updated. Additionally, after returning from the hospital, there was no documentation of monitoring the repaired laceration site for infection or status. This resident had a subsequent fall with similar deficiencies in post-fall investigation and intervention. Another resident with moderate cognitive impairment, hemiplegia, and a history of falls experienced multiple unwitnessed falls, often while attempting to self-transfer. Despite repeated incidents, there was no documentation of root cause investigations, new interventions, or care plan updates. In one instance, the intervention provided was not appropriate given the resident's documented behavior. A third resident with moderate cognitive impairment and a history of falls, including one with a major injury, also experienced multiple falls without consistent root cause analysis, new interventions, or care plan updates. In some cases, interventions implemented were already in place, and there was no documentation of family notification or IDT review.