Failure to Complete Post-Fall Assessments and Documentation
Penalty
Summary
A resident with a history of metabolic encephalopathy, depression, and generalized muscle weakness, and who was assessed as having severely impaired cognitive skills and high risk for falls, experienced a fall after attempting to stand from a wheelchair. Following this incident, the facility failed to complete the required 72-hour neurological checks as indicated in the resident's care plan. Multiple entries on the neuro check list were left blank, and both the LVN and DON confirmed that these missed assessments could have resulted in undetected neurological changes. Additionally, the facility did not complete a post-fall fall risk assessment for the resident after the incident. The LVN stated that such an assessment is necessary to identify ongoing risks and to inform the interdisciplinary team (IDT) in developing appropriate interventions. The DON confirmed that the absence of this assessment meant the resident's risk factors were not re-evaluated after the fall. The documentation for the IDT meeting held after the fall was also incomplete. While the progress note listed staff participants, it did not include post-fall recommendations or a documented plan of care. The DON acknowledged that without this documentation, the discussed interventions would not be implemented as part of the resident's care plan.