Falls -with every fall event there is a catastrophe, which either
- has occurred.
- could have occurred or
- if an existing flaw goes undiscovered and uncorrected, may occur in the future.
There is all too often an overlooked or under-appreciated connection between in-room falls and delayed answering of call lights-particularly in ALFS Level 1. Investigate any fall or any call light complaint thoroughly.
Start with the resident and/or family members him, her or themselves; if they are consistent and credible they can be the best initial source of the truth.
- Staff-they can be helpful but…
- Records-of course they should be reviewed but beware of what is not regularly recorded.
- Systems-the more automatic, the better and more reliable.
- The Administrator-Are they a good one or a bad one? Are they transparent?
- Staff-are they trained; do they respect the Administrator; is turnover/continuity of staff a problem?
- Conduct every investigation in such a manner that takes into account answers to these questions.
Documentation-Care plans, progress notes and policies and procedures
- Look for compliance with written care plans and policies and procedures.
- Look for patterns/protocols/procedures/habits/routines not required in the care plans or policies and procedures but nevertheless followed.
- Identify both compliance and lapses in those patterns, protocols and procedures.
- Find out why there is compliance and/or lapses and prescribe necessary remedies.
Ombudsman-one real job
- To advocate for the residents.
- To ensure resident rights are strictly enforced.
- No goal other than 100% enforcement should be acceptable for anyone in the elder care chain of care and service.
Resident and Staff Safety
- Failures, even with the building itself, resulting in injury or death are not product liability issues.
- Such failures are health and safety issues for all residents, families and staff.
- Always err on the side of health and safety-take the broadest possible investigative approach and involve the whole state team when and where necessary.
- Do a "root cause" quality analysis-fix it quickly but make sure there is a permanent solution.
- Reporting should be encouraged and watch out for and do not tolerate retaliation both obvious and subtle.