Inaccurate Fall Risk Assessments for Resident with Seizure History
Penalty
Summary
The facility failed to ensure that a resident with a history of convulsions received accurate post-fall and comprehensive fall risk assessments. Multiple fall risk assessments for the resident incorrectly indicated that there were no predisposing factors such as seizures, despite the resident's admission record documenting a history of seizures and ongoing use of antiseizure medication (Keppra). Additionally, the assessments did not accurately reflect the resident's medication regimen, which included both antiseizure and psychotropic medications. These inaccuracies were confirmed by a licensed nurse during a review of the resident's clinical record. The Director of Nursing acknowledged that the fall risk assessments were not completed accurately and emphasized the importance of these assessments in determining fall risk and developing appropriate interventions. The facility's policy requires that fall risk assessments be completed upon admission and that relevant findings and interventions be documented and updated in the care plan. The failure to accurately complete these assessments potentially resulted in a subsequent fall for the resident 14 days later, as the resident's fall risk was not properly identified or addressed.