Failure to Complete Post-Fall Follow-Up Assessments and Documentation
Penalty
Fine: $16,020
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to complete required follow-up assessments after a resident experienced a fall. Clinical record review and staff interviews revealed that, although the interdisciplinary team met to discuss the fall and performed a root cause analysis, there was no documentation of follow-up actions such as pain assessments, vital signs, or neurological checks in the resident's record. Additionally, no incident report was found for the fall, and staff confirmed that the nurse on duty at the time did not initiate the required documentation. The absence of follow-up assessments and documentation occurred despite facility protocol requiring these actions after a fall.