Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to accurately assess a resident for fall risk, as evidenced by multiple inaccuracies in the resident's Fall Risk Assessment. The assessment did not document two recent falls experienced by the resident—one unwitnessed fall in the facility and another in the community that resulted in severe injury, hospitalization, and subsequent admission to the facility. Additionally, the assessment failed to record several high-risk medications that the resident was prescribed, including a diuretic, antihypertensive, narcotic, and sedative. Both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed during interviews and medical record reviews that the Fall Risk Assessment contained these inaccuracies. They acknowledged that the resident's fall risk score would have been higher if the assessment had been completed accurately, reflecting the true number of falls and the medications taken. The facility's policy required staff to identify specific risks and causes to prevent falls, but this was not followed in this case.