Failure to Prevent Avoidable Fall and Incomplete Root-Cause Analysis
Penalty
Summary
A deficiency occurred when the facility failed to prevent an avoidable fall and did not conduct a thorough root-cause analysis for a resident who sustained significant injuries, including fractures of the clavicle and thoracic vertebra. The resident had a history of repeated falls, stroke, heart disease, vascular dementia with behaviors, and adjustment disorder, and was on hospice care. On the day of the incident, the resident was found on the floor next to their bed with visible injuries. Both the nurse and CNA who responded to the incident observed that the bed was at an unusually high position, approximately waist level, despite both reporting that it had previously been left in the lowest position after care was provided. The facility's investigation into the incident was limited and did not identify a root cause for the fall. Statements from staff were collected, including a housekeeper who denied raising the bed and claimed to have entered the room only after the incident. The investigation did not include a review of available hallway camera footage to verify the timeline or determine if anyone else entered the room and raised the bed. Additionally, there was no documentation in the resident's care plan or clinical record indicating that the resident had a history of manipulating bed controls or exhibiting restless behaviors that could explain the bed being raised. Despite suggestions from facility leadership that the resident may have raised the bed themselves due to restlessness, there was no supporting evidence in the clinical record or staff interviews to substantiate this claim. The facility's investigation file lacked a documented root cause analysis, and the interdisciplinary team did not provide an analysis as required by the facility's own Falls Reduction Program policy. The failure to ensure the bed was kept in the lowest position and to conduct a comprehensive investigation into the circumstances of the fall contributed to the deficiency.