Failure to Accurately Assess Fall Risk for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, chronic confusion, and gait/balance disturbances was not accurately assessed for fall risk upon admission. The resident, who required significant assistance with mobility and activities of daily living, was incorrectly identified as low risk for falls due to an incomplete fall risk assessment. The assessment failed to include critical information such as the gait/balance section, resulting in an inaccurate score. Additionally, there were inconsistencies in the documentation of the resident's cognitive status, with the admission assessment indicating alert and oriented status, while other records noted chronic confusion and mild cognitive impairment. The incomplete and inaccurate assessment led to the resident not being properly identified as high risk for falls. Subsequently, the resident experienced an unwitnessed fall, sustaining a laceration and a bruise. Interviews with facility staff revealed that the electronic medical record system sometimes generated incorrect scores when sections of the assessment were left incomplete, and the nurse responsible for the assessment acknowledged the errors but did not provide a clear explanation for the discrepancies in documentation.