Failure to Complete Fall Risk Assessment Upon Admission
Penalty
Summary
A resident with a history of falls, diabetes mellitus, muscle weakness, and anemia was admitted to the facility. Upon admission, the facility failed to complete a fall risk assessment for this resident, despite the facility's policy requiring such an assessment within 2 to 24 hours of admission. The resident's records, including the Minimum Data Set, indicated a need for moderate to maximal assistance with daily activities and transfers, and documented a history of falls. The care plan, revised over a month after admission, identified the resident as being at risk for recurrent falls and injury due to deconditioning and balance problems. During interviews, both a registered nurse and the Director of Nursing confirmed that the fall risk assessment was not completed upon admission, acknowledging that the assessment is necessary to identify residents at risk and to initiate appropriate fall prevention interventions. The facility's policy on fall management specifically requires a fall risk evaluation for each new admission, and the omission in this case was recognized as a failure to follow established procedures.