Failure to Investigate and Document Resident Falls and Implement Appropriate Interventions
Penalty
Summary
The facility failed to ensure that resident falls were thoroughly investigated, documented, and that appropriate interventions were implemented and followed for two residents reviewed for falls. For one resident with multiple complex diagnoses and a history of repeated falls, the facility did not consistently document or investigate the circumstances of each fall, such as the resident's footwear, the number of staff assisting, or the last time the resident was toileted, even when multiple falls occurred in the bathroom or on the way to the bathroom. Interventions were often added after each fall, but there was a lack of evidence that these interventions were always implemented or effective, and staff statements were frequently missing from the fall investigations, including for witnessed falls. The care plan was not always updated to reflect new interventions, and some interventions were documented as being in place when they were not, according to staff interviews. For another resident with a history of cerebral infarction and chronic pain, the facility did not consistently document falls or complete required neurological checks after a fall. There were discrepancies in the documentation regarding whether falls were witnessed or unwitnessed, and not all falls were recorded in the incident accident log. Neuro checks were not completed according to the required schedule, with a significant gap of 16 hours between checks, and there was no evidence of progress notes or fall investigations for some reported falls. The facility's fall management policy did not provide clear guidance on fall investigations beyond the requirement for the charge nurse to gather information. Interviews with facility leadership confirmed the lack of thorough documentation, missing staff statements, and inconsistencies in the implementation and documentation of fall interventions. The facility was unable to provide evidence of staff following care plan interventions at the time of several falls, and new interventions were sometimes added without clear rationale or supporting documentation. The deficiencies were identified through staff interviews, record reviews, and observation of facility practices related to fall prevention and investigation.