Failure to Complete Quarterly Fall Risk Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two out of three residents reviewed, specifically regarding the completion of quarterly fall risk assessments. One resident, admitted with respiratory disorders and difficulty walking, did not have any quarterly fall risk assessments documented in their clinical record. This resident experienced an incident where they slid down from the commode and ended up on the floor, as noted in a change in condition evaluation. Another resident, admitted with dementia, also lacked a quarterly fall risk assessment during a specified period. This resident was found sitting on the floor next to her bed after attempting to ambulate to the bedside commode and feeling weak. During an interview, the DON confirmed that both residents did not have the required quarterly fall risk assessments completed, as stipulated by the facility's Fall Prevention Program policy, which mandates a fall risk assessment every 90 days and upon changes in a resident's condition. The absence of these assessments meant that the residents' fall risk and prevention strategies were not updated in accordance with their current conditions.