Failure to Complete Required Post-Fall Evaluation and Fall Risk Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete required post-fall evaluations and assessments in accordance with its own policies after a resident fall. A resident admitted in December 2025 with Alzheimer’s disease, transient ischemic attack, depression, and impaired physical mobility related to Parkinson’s disease had been care planned as being at risk for falls and required assistance with personal hygiene, toileting, bathing, and transfers/ambulation with a walker. The admission MDS documented moderate cognitive impairment and a need for substantial assistance with activities of daily living and mobility. On 12/26/25 at 7:03 AM, the resident was found on the floor in a prone position between the bed and closet after attempting to go to the bathroom and hitting his/her head. The provider was notified and ordered transfer to the emergency department. Although a Post Fall assessment was completed for this fall event, the clinical record showed that the required Fall Risk assessment and Post Fall evaluation were not completed. In an interview, the ADON stated that each fall incident should be followed by a Fall Risk assessment and Post Fall evaluation, and that it was the responsibility of the assigned nurse to complete these documents. Facility policies directed that a fall risk evaluation be performed on admission, with change of condition, annually, quarterly, or as needed, and that all residents be assessed for potential/actual injury after a fall, but these requirements were not fully carried out for this resident’s fall.
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