Failure to Conduct Thorough Investigation After Resident Fall
Penalty
Summary
The facility failed to ensure a thorough investigation following a fall incident involving a resident with multiple diagnoses, including palliative care, atrial fibrillation, congestive heart failure, unspecified dementia, chronic kidney disease, and a history of falling. The resident, who had moderate cognitive impairment and required an assist of one with a gait belt and walker for transfers, fell during a transfer from the bathroom to a wheelchair. At the time of the fall, the resident was not using a gait belt or non-slip footwear as specified in the care plan. The Certified Nursing Assistant (CNA) involved did not follow proper safety measures during the transfer. After the incident, the facility's investigation was limited to interviewing the resident and the CNA involved. There was no documentation that other residents were interviewed or assessed for similar concerns regarding the CNA's transfer practices. The Director of Nursing confirmed that no additional residents were interviewed to determine if there were other instances of unsafe transfers or potential neglect. This lack of a comprehensive investigation did not align with the facility's abuse prevention policy, which requires a systematic approach, including interviewing other residents to assess for possible abuse or neglect.