Failure to Complete Required Fall Investigations for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to investigate resident falls in accordance with its own accident and incident policy, which required staff to report all accidents or injuries to a supervisor, complete an Accident or Incident Report Form, and obtain witness statements from the resident and any staff present or first to find the resident. The Regional Clinical Director stated that these reports and witness statements were used to investigate falls, determine their cause, and prevent recurrence. However, for three sampled residents, the required investigations were either not completed or were incomplete, despite documented falls and existing care plans identifying them as being at risk for falls. For one resident with muscle weakness and a history of craniotomy, who was cognitively intact and partially dependent for ADLs, the record showed two falls—one unwitnessed fall between beds in the room and another fall when the resident stood from a wheelchair while a nurse aide was preparing for a shower—without documented evidence of a thorough investigation. Another resident with anoxic brain damage, respiratory failure with hypoxia, persistent vegetative state, and contractures, who was cognitively impaired and dependent for bed mobility, was found with his head on the floor and feet still on the bed after an unwitnessed fall, again without documented evidence of a thorough investigation. A third resident with cerebral infarction, anxiety, and seizures, who was dependent on staff for toileting and dressing, was found on the floor near the bathroom door, with no documented evidence that any investigation was completed. The Regional Clinical Director confirmed that there was no investigation for the third resident’s fall and that the investigations for the first two residents’ falls were incomplete, despite the expectation that full investigations should have been conducted.
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