Failure to Accurately Assess and Address Fall Risk
Penalty
Summary
Nurses at the facility failed to demonstrate competency in assessing fall risk for a resident with a complex medical history, including dementia, multiple falls, and a recent hip fracture. The resident was admitted for hospice care and had diagnoses such as narcotic poisoning, vascular dementia, contractures, and chronic pain. Despite a documented history of multiple falls and significant physical and cognitive impairments, the resident was repeatedly assessed as a low fall risk by an LVN using the Morse Fall Scale on two separate occasions. These assessments did not accurately reflect the resident's condition or history, as the resident required substantial assistance with mobility and activities of daily living and was not aware of his own abilities. The care plan for the resident identified him as being at risk for falls due to medication use, cognitive impairment, vision issues, weakness, and a history of falls. Interventions included close monitoring, keeping the bed in the lowest position, ensuring the call light and personal items were within reach, and providing a clutter-free environment. However, observations revealed that the resident's bed was not always kept in the lowest position, and staff were not consistently aware of the resident's fall history. Additionally, the LVN responsible for the fall risk assessments admitted to needing more training on the assessment tool and acknowledged that the assessments were inaccurate. Interviews with facility staff, including the DON and the administrator, confirmed that the assessments were not completed accurately and that the resident should have been identified as a high fall risk. The facility's policies required accurate identification of fall risk and individualized care planning, but these were not followed in this case. The failure to accurately assess and document the resident's fall risk led to insufficient interventions being implemented for the resident's safety.