Failure to Complete Required Fall Risk Assessments
Penalty
Summary
The facility failed to complete required fall risk assessments for one resident who was admitted with multiple diagnoses, including Major Depressive Disorder, Benign Prostatic Hyperplasia, Hypertension, Diabetes, and Cerebral Ischemia. The resident experienced a fall resulting in a right hip fracture. According to the facility's Fall Prevention Program policy, a fall risk assessment should be performed at least quarterly, upon admission, after any fall, and with any significant change in condition. However, the resident's medical record did not contain documentation of a fall risk assessment from November 2024 through August 2025. This lack of assessment was confirmed by both the DON and a regional RN, who verified that the required quarterly assessments were not completed during this period.