Failure to Complete Post-Fall Risk Assessment
Penalty
Summary
A deficiency was identified when a resident with a history of falls, dementia with behavioral disturbances, and Parkinson's disease experienced a fall. The resident's care plan indicated interventions such as keeping the call light within reach, encouraging the resident to call for assistance, and providing help with bed mobility, transfers, and ambulation. After the fall, the resident was found sitting on the floor, assessed for injuries, and assisted back to bed. Documentation showed no injuries or distress following the incident. However, a review of the clinical record revealed that the required fall risk assessment, specifically the Morse Fall Scale, was not completed after the fall as mandated by facility policy. The next documented fall risk assessment occurred four months later. Interviews with the DON and Regional Nurse confirmed that the Morse Fall Scale should have been completed after the fall, in accordance with policy, but this was not done. Facility policy directs that a fall risk assessment must be completed and documented in the medical record after any fall.