Inaccurate Fall Risk Evaluation Documentation
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding the Fall Risk Evaluation for one resident. The resident, who lacked decision-making capacity, experienced a fall as documented in the SBAR Communication Form. However, the Fall Risk Evaluation completed on the same day did not reflect this incident, instead indicating that the resident had no falls in the past three months. This discrepancy was confirmed during interviews and record reviews with both a registered nurse and the Director of Nursing, who acknowledged that the fall should have been included in the evaluation. Facility policies required that post-fall assessments and care plan changes be completed for all residents who experienced a fall, and that medical records provide a concise and accurate account of care and resident condition. The licensed nurse responsible for the Fall Risk Evaluation did not document the recent fall, resulting in an inaccurate record. This inaccuracy was verified by facility staff during the survey process.