Failure to Accurately Assess and Document Fall and Elopement Risks
Penalty
Summary
The facility failed to accurately assess and document the safety risks of two residents, resulting in deficiencies related to fall and elopement prevention. For one resident with a history of falls, the Fall Risk Evaluation completed on 9/19/24 was incorrectly scored, omitting points for medications that increase fall risk, despite the resident receiving hypoglycemic, diuretic, and psychotropic medications daily. This led to an underestimation of the resident's fall risk. Additionally, no subsequent quarterly Fall Risk Evaluations were completed after 9/19/24, nor was an evaluation performed after the resident experienced a fall on 2/10/25 that required medical care outside the facility. The administrator confirmed these assessments were not completed as required and that there was no facility policy for Fall Risk Assessment. For another resident with a history of elopement, the initial Elopement Risk Evaluation and the post-elopement evaluation both failed to identify the resident as at risk, even after an actual elopement event. The evaluation incorrectly marked that the resident had no history of elopement, despite the incident. The administrator acknowledged the error in scoring and confirmed that the evaluations did not accurately reflect the resident's risk status. The facility's policy required a systematic approach to monitoring and managing residents at risk for elopement, including proper identification and assessment, which was not followed in this case.