Failure to Complete Thorough Fall Investigations for High-Risk Resident
Penalty
Summary
A resident with multiple complex medical conditions, including hypertensive encephalopathy, hemiplegia, prostate cancer, chronic pulmonary embolism, anemia, gout, dementia, and depression, was identified as being at high risk for falls. The resident experienced three unwitnessed falls within the facility. Despite the facility's policy requiring thorough post-fall investigations, including root cause analysis and staff statements, these procedures were not consistently followed for each incident. For the first two falls, no Post-Fall Investigation Forms were completed, and there was a lack of documentation regarding what the resident was doing prior to the falls, what interventions were in place, and whether those interventions were effective. The third fall had a Post-Fall Investigation Form completed, but it lacked staff statements and did not provide input on interventions to prevent further falls. The absence of thorough investigations prevented the identification of root causes and the implementation of effective fall prevention strategies. Interviews with the DON revealed that prior to their tenure, thorough investigations were not being completed, and although new policies and training were implemented, the required investigative steps were still not followed for these incidents. The facility was unable to provide explanations for the lack of comprehensive investigations for the resident's three falls, resulting in a failure to ensure adequate supervision and accident prevention as required by facility policy.