Failure to Complete Required Post-Fall Assessments and Documentation
Penalty
Summary
The facility failed to ensure that resident assessments and post-fall assessments were completed following falls for one resident with a history of severe cognitive impairment and high fall risk. Despite the facility's policies requiring incident reports, neuro checks, fall investigations, staff statements, and completion of fall assessments in the electronic medical record after each fall, these procedures were not consistently followed. Specifically, for three separate falls, the facility was unable to provide the required resident assessments, post-fall assessments, or staff statements as outlined in their protocols. Medical record reviews showed that the resident experienced multiple falls in the bathroom, with documentation indicating no injuries but repeated high fall risk scores. Progress notes and incident reports described the circumstances of each fall, but the necessary follow-up documentation and assessments were missing. Interviews with the DON confirmed that the required assessments and staff statements were not completed or available for review, despite the facility's policy and the resident's high risk for falls.