Failure to Accurately Reassess Fall Risk After Resident Fall
Penalty
Summary
The facility failed to conduct an accurate fall reassessment for one resident following a fall incident. The resident, who had diagnoses including muscle weakness, diabetes mellitus, and hemiplegia, was admitted with significant physical and cognitive impairments. The initial fall risk evaluation identified the resident as high risk, noting incontinence, balance problems, and the use of assistive devices. However, after the resident was found on the floor in their room, the subsequent fall risk evaluation did not document the recent fall, omitted the resident's incontinence and use of a wheelchair, and assigned a lower fall risk score. During interviews and record reviews, it was confirmed that the fall risk reassessment was incomplete and inaccurate. The MDS Nurse acknowledged that the evaluation did not reflect the resident's true risk factors and that the incorrect scoring could result in improper care planning. Facility policy required appropriate assessment and interventions after a fall, but these were not followed in this instance.