Failure to Complete Quarterly Fall Risk Evaluation
Penalty
Summary
The facility failed to ensure that a Fall Risk Evaluation was completed quarterly for a resident with multiple risk factors for falls, including dementia, anxiety, muscle weakness, a history of falls, and macular degeneration. The resident's care plan identified several fall risk factors and included interventions such as instructing the resident to request assistance, maintaining a clutter-free and well-lit environment, and providing rest periods. Despite these measures, documentation review revealed that no Fall Risk Evaluation was completed during a four-month period, which overlapped with a comprehensive assessment. During this period, the resident experienced an unwitnessed fall, resulting in a head injury that required emergency department evaluation. Interviews with the DON confirmed that facility policy requires fall risk assessments on admission, quarterly, after falls, and with any health changes, and acknowledged that the required evaluations were not completed as scheduled. The facility's policy also directed that fall risk assessments be performed at these intervals, but there was no documentation of such assessments during the specified timeframe.