Failure to Complete Timely Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that post-fall assessments were conducted according to its own Falls Assessments/ Falls Risk Policy for one resident. The policy required that any resident who experienced a fall receive weekly assessments for twelve weeks, with the assessment period resetting if another fall occurred. A review of the clinical record for a resident with diagnoses including muscle weakness, hypertension, osteoarthritis, and severe cognitive impairment revealed that the resident had a history of falls and experienced a witnessed fall from the side of the bed. Although an initial assessment and notifications were completed after the fall, the required weekly fall risk assessments were not performed as stipulated by facility policy. Documentation showed that after the resident's fall, only one fall assessment was completed several weeks later, with no assessments conducted in the immediate weeks following the incident. Interviews with the DON, MDS Coordinator, and Administrator confirmed that the required weekly assessments were not completed after the fall, and that the facility's policy was not followed. This lapse in conducting timely post-fall assessments constituted a deficiency in providing adequate supervision and accident hazard prevention.