Where perfection is the only acceptable goal.

Falls -with every fall event there is a catastrophe, which either

  1.  has occurred.
  2.  could have occurred or
  3.  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.

  1.   Staff-they can be helpful but…
  2.   Records-of course they should be reviewed but beware of what is not regularly recorded.
  3.   Systems-the more automatic, the better and more reliable.


  1.   The Administrator-Are they a good one or a bad one?  Are they transparent?
  2.   Staff-are they trained; do they respect the Administrator; is turnover/continuity of staff a problem?
  3.   Conduct every investigation in such a manner that takes into account answers to these questions.

Documentation-Care plans, progress notes and policies and procedures

  1.  Look for compliance with written care plans and policies and procedures.
  2.  Look for patterns/protocols/procedures/habits/routines not required in the care plans or policies and procedures but nevertheless followed.
  3.  Identify both compliance and lapses in those patterns, protocols and procedures.
  4.  Find out why there is compliance and/or lapses and prescribe necessary remedies.

Ombudsman-one real job

  1.  To advocate for the residents.
  2.  To ensure resident rights are strictly enforced.
  3.  No goal other than 100% enforcement should be acceptable for anyone in the elder care chain of care and service.

Resident and Staff Safety

  1.  Failures, even with the building itself, resulting in injury or death are not product liability issues.
  2.  Such failures are health and safety issues for all residents, families and staff.
  3.  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.
  4.  Do a "root cause" quality analysis-fix it quickly but make sure there is a permanent solution.
  5.  Reporting should be encouraged and watch out for and do not tolerate retaliation both obvious and subtle.


Fort Pierce, Florida



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