Failure to Complete and Accurately Document Fall Risk Assessments After Resident Falls
Penalty
Summary
The facility failed to ensure that fall risk assessments were completed accurately and in a timely manner for two residents, resulting in deficiencies related to accident prevention and supervision. For one resident, who had diagnoses including metabolic encephalopathy, lack of coordination, and mild cognitive impairment, the facility did not accurately document a fall that occurred. Despite the resident being found on the floor next to her bed, the subsequent fall risk assessments incorrectly indicated that she had not fallen in the previous 90 days. Both the registered nurse and the director of nursing confirmed that this omission was incorrect and could affect the accuracy of the fall risk score. Another resident, admitted with unspecified dementia, Alzheimer’s disease, and lack of coordination, experienced a witnessed fall when sliding from a wheelchair to the floor. However, after this incident, licensed staff did not complete a fall risk assessment as required by facility policy. Both the MDS nurse and the assistant director of nursing acknowledged that a fall risk assessment should have been completed after the fall, in accordance with the facility’s procedures for assessing falls and their causes. The facility’s policies and procedures specify that after a fall, staff must complete a fall risk assessment, document appropriate interventions, and record relevant information in the resident’s medical record. In both cases, the failure to follow these procedures resulted in incomplete or inaccurate documentation of fall risk, which could impact the identification and implementation of interventions to prevent further falls.