Failure to Investigate Unwitnessed Fall and Missing Personal Property
Penalty
Summary
The deficiency involves the facility’s failure to conduct a complete investigation of an unwitnessed fall for one resident. This resident was admitted with muscle weakness and unsteadiness on feet, and a public complaint alleged that the resident slept in a wheelchair and slipped out onto the floor. The facility’s unwitnessed fall investigation from that night documented that staff found the resident seated on the floor with the electric wheelchair positioned behind the resident at 12:20 AM, but the investigation lacked witness statements, a root cause analysis, and documentation confirming whether abuse or neglect had been ruled out. A registered nurse later stated she typically completed investigations for risk management but did not recall completing this unwitnessed fall investigation, and administration confirmed the investigation should have contained a root cause analysis, witness statements, and documentation excluding abuse or neglect. The deficiency also includes the facility’s failure to investigate a report of misappropriation of property for another resident. This resident, admitted with muscle weakness and diabetes, reported through a grievance that a phone that had been plugged in went missing around 1:00 AM, and a public complaint indicated the resident reported the missing phone to the police. Review of the clinical record showed no documentation of any investigation into the missing phone. The Social Services Director stated that an investigation should have been completed and noted the grievance focused on replacing the phone rather than determining how the phone went missing, and administration confirmed that an investigation into the missing phone should have been completed.
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