Root Cause Analysis Following Fall Incidents at Nursing Homes in Florida

Root Cause Analysis Following Fall Incidents at Nursing Homes in Florida

Date: 24 October 2023 | Blog | Nursing Home Neglect | Falls | By: Sanga Turnbull

"Someone fell again," you might overhear staff say at a nursing home in Florida. But if you dig a little deeper, you'll find that every fall has a backstory—a complex mix of circumstances, decisions, and, well, gravity. The crux of it all? Root cause analysis. This is where the rubber meets the road in making tangible changes that ensure resident safety.

The Nuts and Bolts of Root Cause Analysis

In essence, root cause analysis is a structured, team-based investigation that seeks to determine the real cause of an incident and how to fix it. It isn't just a cursory glance; it's a deep dive. In Florida nursing homes, RCA is often mandated after falls to comply with both federal and state regulations.

The Initial Response: Stop the Bleeding, Literally and Figuratively

The first step is immediate care for the fallen resident, obviously. But alongside medical care, the internal investigation starts ticking. Florida law requires nursing homes to report any serious incidents, including falls, to the Agency for Health Care Administration (AHCA) within a specific timeframe.

Data Collection: Gathering the Pieces of the Puzzle

Nursing homes then gather data—CCTV footage, staff interviews, resident medical records, and environmental assessments. It's a full-on Sherlock Holmes operation, but with clipboards instead of a magnifying glass. A multidisciplinary team usually conducts the RCA. We're talking nurses, therapists, administration, and sometimes even family members.

The Analysis: Where Things Get Technical

The actual analysis may use various tools, from fishbone diagrams to "Five Whys" analyses. The goal here is to identify root causes, not just superficial ones. Are staffing levels adequate? Is the lighting sufficient? Was the resident properly assessed for fall risk?

Intersecting With Florida State Regulations

You'd better believe Florida has rules on this. For example, the Florida Administrative Code Rule 59A-4.107 focuses on resident care policies and procedures, mandating that nursing homes implement plans to minimize hazards that contribute to falls.

Action Plans and Preventive Measures

Finally, an RCA should conclude with an action plan aimed at reducing the risk of similar incidents occurring. Because at the end of the day, it's all about creating a safer environment for the residents, isn't it?

If you believe that a nursing home did not conduct a root cause analysis and your loved one suffered a fall and injury, reach out to our firm for your free consultation.

Call 407.612.6464 • 863.324.3500 today to speak with an experienced Nursing Home Abuse and Neglect Lawyer who proudly serves Lakeland, Orlando, and throughout the State of Florida.