Failure to Accurately Complete Fall Risk Assessment
Penalty
Summary
The facility failed to accurately complete fall risk assessments for a resident with multiple diagnoses, including repeated falls, dementia, schizophrenia, anxiety disorder, and major depressive disorder. The resident's care plans, revised on several occasions, documented a history of falls, impaired safety awareness, wandering, and the need for supervision and assistance with mobility and activities of daily living. Despite these documented risks and functional deficits, the resident's Fall Risk Assessment dated 2/12/25 indicated that the resident was 'Not at Risk for Falls,' and described the resident as chair bound with gait and balance marked as not applicable. The Minimum Data Set (MDS) for the resident showed a BIMS score of 00, indicating severely impaired cognition, and documented that the resident required partial/moderate assistance to walk 10 feet. The resident experienced an unwitnessed fall on 4/7/25, resulting in an injury that required hospital evaluation and sutures. Observations on 4/20/25 found the resident attempting to stand without footwear and unable to identify the call light, further demonstrating cognitive and functional impairments. Interviews with facility staff, including the ADON, MDS Coordinator, and DON, confirmed that the fall risk assessment was not completed accurately and emphasized the importance of proper assessment for implementing appropriate interventions. Facility policies required fall risk assessments to be performed at admission, quarterly, after significant changes, and after any fall incident, with interventions tailored to identified risks. The failure to accurately assess the resident's fall risk led to a lack of appropriate interventions, as documented in the facility's policies and staff interviews. The deficiency was identified through record review, staff interviews, and direct observation of the resident's condition and environment.