Inaccurate Fall Risk Assessments and Incomplete Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, specifically regarding fall risk assessments. The fall risk assessments dated 8/18/25 and 8/30/25 did not indicate whether the resident was at low or high risk for falls. Additionally, one of the fall risk assessments inaccurately documented that the resident had no history of falls, despite the resident having a previous fall history. These inaccuracies were confirmed during a review of the records with the registered nurse supervisor, who acknowledged that the assessments did not properly reflect the resident's fall risk status or history. The resident involved had multiple diagnoses, including diabetes, dysphagia, lack of coordination, and an above-knee amputation of the right leg. The Minimum Data Set assessment indicated the resident had moderately impaired cognition and required significant assistance with activities of daily living. The facility's policy required nursing documentation to be concise, clear, pertinent, and accurate, but the fall risk assessments did not meet these standards, resulting in an incomplete and inaccurate medical record for the resident.