Failure to Investigate, Document, and Intervene After Multiple Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Prevention Program and Incident/Accident policies for a resident with severe cognitive impairment and total dependence for ADLs and transfers. The resident, who had athetoid cerebral palsy, anxiety, and a developmental speech and language disorder, was care planned as being at risk for falls related to immobilization and decreased cognition. Despite this, the resident experienced multiple falls in a short period, including falls at the nurses’ station and in the Assisted Dining Room (ADR), while dependent on staff for safety and supervision. On one occasion, therapy staff observed the resident lean forward in a wheelchair and fall, striking her head on a sharps container and nurses’ cart. On another documented fall at the nurses’ station, the resident was noted as alert but disoriented at baseline. The facility’s own policies required completion of incident/accident reports for all accidents, assessment and documentation of injuries and vital signs, physician and family/legal representative notification, and care plan updates with appropriate interventions after each fall. However, for a fall that occurred in the ADR on 12/3, staff statements show the resident was found on the floor tipped back in her wheelchair, but no incident report was completed, no nursing note was entered, no notifications were made to the physician or the resident’s representative, and no new interventions were implemented. Additional documentation and interviews show that the resident had further falls in the ADR on subsequent dates, and that at least one of these later falls also did not result in new interventions being put in place. The incident/accident log omitted the 12/3 ADR fall entirely, despite staff and a resident witness describing that the resident fell backwards in her wheelchair in the ADR while no staff were present, and that another resident had to yell repeatedly for help. The resident’s representative reported being informed of only three falls and stated she would have wanted to know about other falls. Overall, the facility failed to prevent falls, failed to investigate at least one fall, failed to notify the physician and resident representative of two falls, and failed to implement fall-related interventions after two of the resident’s falls, contrary to its written policies and fall prevention program.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.