Inaccurate Fall Risk Assessments by Nursing Staff
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competency in completing fall risk evaluations for multiple residents. In one case, a resident with a history of falls and a recent major injury (fractured rib) was assessed as high risk for falls prior to and after the incident, but a subsequent evaluation by an RN recorded a significantly lower score, indicating low risk, without justification. The Director of Nursing confirmed that the evaluation was completed improperly and that staff are expected to question such discrepancies. Similar issues were identified for two other residents: one with a history of recurrent falls and a femur fracture, whose fall risk assessment after a third fall was incomplete and scored much lower than previous assessments, and another resident whose post-fall assessment was also incomplete and showed a lower risk score than prior evaluations. These deficiencies were identified through interviews and record reviews, which revealed that fall risk assessments were not completed accurately or thoroughly, particularly in the areas of gait/balance and medications. The improper completion of these assessments placed the affected residents at risk of avoidable adverse outcomes, as their true fall risk status was not accurately reflected in their care plans.