Failure to Assess and Document Resident Fall
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A resident experienced a witnessed fall, but the facility failed to document the incident in the medical record. There was no incident report created for the fall, and no post-fall assessment was completed. The resident's care plan was not revised or updated to reflect the fall incident or the resident's condition following the event. During an interview, the Regional Clinical Nurse Manager confirmed that fall assessments are required after resident falls, but acknowledged that in this case, the required assessment and care plan revision were not completed. The deficiency was identified through a review of the resident's medical record and staff interviews, which revealed the lack of appropriate documentation and follow-up after the fall.