Incomplete Fall Risk Documentation for Dependent Resident With Paraplegia
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident by not correctly documenting the resident’s fall risk status on Fall Risk Observation/Assessment forms. The resident was admitted with diagnoses including paraplegia, osteoarthritis of the hip, and a stage 4 sacral pressure ulcer, and the H&P documented fluctuating capacity to understand and make decisions. An MDS assessment indicated the resident was dependent on staff for toileting hygiene, personal hygiene, showers, dressing, and transfers. Despite these conditions, the Fall Risk Observation/Assessment forms dated 10/20/2025 and 11/24/2025 indicated the resident did not have neuromuscular or functional health conditions and risk factors for falls such as loss of arm or leg movement. During a concurrent interview and record review, the DON confirmed that the Fall Risk Observation/Assessment form is one of the tools used to evaluate residents’ fall risk and provide necessary care and interventions, and that the form generates a score based on the answers provided. The DON stated that the resident’s Fall Risk Observation/Assessment forms were incomplete and did not indicate the diagnosis of paraplegia, which resulted in a lower fall risk score. The facility’s Charting and Documentation policy required that all services, progress toward care plan goals, and any changes in the resident’s condition be documented in an objective, complete, and accurate manner to facilitate communication among the interdisciplinary team, but this standard was not met for this resident’s fall risk documentation.
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