Complaint Investigation Report

The policy also requires that all witnessed or unwitnessed falls be documented in the Brookdale Incident Reporting System (BAIRS), that a post-fall evaluation be conducted to identify interventions to prevent future falls, and that the service plan be reviewed and updated accordingly. Additionally, the policy requires that falls be tracked and trended for quality improvement purposes.

Based on records provided by the facility, there was no documentation demonstrating that a fall risk assessment was completed upon R1’s admission. Furthermore, there was no evidence that post-fall evaluations were conducted following R1’s repeated falls, nor that interventions and or fall prevention plan were implemented or documented. The Personal Service Plan was not updated to reflect R1’s history of falls and related injuries. Overall, the facility did not follow its own policies and procedures regarding fall risk assessment, post-fall evaluation, care planning, and documentation for a resident with a history of falls.

As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

An Exit Interview was conducted with (FDA) Arrellano and a copy of this report was provided to the facility via email. A certified copy will be sent to the facility mailing address.