Inaccurate Fall Risk Assessments for Residents with Fall History
Penalty
Summary
The facility failed to accurately complete Fall Risk Assessments for four residents with a history of falls. For one resident with multiple diagnoses including hypertension, quadriplegia, and a recent fall, the assessment did not reflect the presence of hypertension or the recent fall, both of which should have increased the fall risk score. The documentation showed that the resident was found on the floor and was unable to describe the incident, but the assessment failed to account for these risk factors. Another resident with a history of falls and a recent traumatic fracture was not properly assessed for previous falls or for medications that increase gastrointestinal motility, which should have contributed to a higher fall risk score. The resident had experienced a fall prior to admission and another incident in the facility, but the assessment recorded no history of falls or relevant medications. Similarly, a third resident with Parkinson's disease and a documented unsteady gait was incorrectly assessed as having independent mobility with a steady gait, despite care plan documentation and observed incidents indicating otherwise. A fourth resident with cerebral infarction and seizures, who was receiving multiple medications known to increase gastrointestinal motility, was also inaccurately assessed as not receiving such medications. The DON confirmed that the Fall Risk Evaluations for these residents were inaccurate and acknowledged that assessments were not being fully completed. The facility's in-service training on Fall Risk Assessments lacked documentation of date, time, and educational content, further contributing to the deficiency.