Failure to Investigate Falls and Update Care Plan
Penalty
Summary
The facility failed to follow its fall occurrence policy by not conducting a post-fall investigation to determine the reasonable cause of two falls experienced by a male resident with dementia, hemiplegia, hemiparesis, heart failure, and a urinary tract infection. The resident had two documented falls, but the Director of Nursing, who also serves as the fall coordinator, acknowledged that no post-fall investigation was completed for either incident. Additionally, the resident's fall care plan was not reviewed or revised with new interventions following these falls, as required by the facility's policy. The facility's policy specifies that the fall coordinator should review incident reports, conduct investigations to determine the cause of falls, and update the care plan with appropriate interventions, none of which were completed in these instances.