Failure to Complete Fall Assessments, Documentation, and Interventions
Penalty
Summary
The facility failed to ensure that fall assessments were completed, falls were documented in the medical record, fall prevention interventions were in place, and fall investigations were thorough for multiple residents. For one resident with a history of syncope, falls, and diabetic neuropathy, there were several instances where falls were either not documented in the medical record, follow-up assessments were missing, or interventions such as non-skid strips were not implemented as care planned. Staff interviews confirmed a lack of awareness regarding required interventions, and documentation did not consistently include vital signs, neurological checks, or pain assessments after falls. Another resident with vascular dementia and a high risk for falls experienced a fall that was not documented in the progress notes until the following day, with no evidence of vital signs being recorded or a comprehensive assessment of a resulting skin tear. The care plan interventions, such as therapy for transfers and keeping the room free of clutter, were not consistently documented as being followed or evaluated after incidents. Staff interviews confirmed gaps in documentation and assessment following falls. Additional residents with cognitive impairment and a history of falls also experienced similar deficiencies. Falls were not consistently documented in the medical record, and there was a lack of detail regarding the circumstances of the falls, whether they were witnessed, and the assessments performed afterward. In one case, neurological checks were not continued as required, and there was no documentation of immediate interventions or witness statements. Facility policy required thorough documentation and assessment after falls, but these procedures were not consistently followed, as confirmed by staff interviews and record reviews.