Failure to Complete Quarterly Fall Risk Evaluations for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete required quarterly fall risk evaluations for two residents in accordance with professional standards and the facility’s Falls Management policy. For one resident with vascular dementia, muscle weakness, anxiety disorder, and a care plan identifying a high risk for falls, the quarterly Fall Risk Evaluation opened on 12/2/25 was left blank with no fall risk score determined. This resident’s care plan included use of a mechanical lift with two staff for transfers, environmental safety measures, and reminders to use the call light, and the quarterly MDS showed significant cognitive impairment and dependence on staff for bed mobility and transfers. On 12/12/25, this resident experienced a witnessed fall when a nurse aide transferred the resident into a wheelchair, the wheelchair locks failed, and the resident fell to the floor, sustaining a bloody nose and a skin tear to the bridge of the nose and requiring transfer to the hospital. A second resident, with diagnoses including polyneuropathy, epilepsy, weakness, and anxiety, also had a quarterly Fall Risk Evaluation opened on 12/10/25 that was left blank with no fall risk score determined. The quarterly MDS documented that this resident was alert and oriented and independent with bed mobility, transfers, and ambulation, and the care plan identified fall risk related to new admission, generalized weakness, syncopal episodes, and seizures, with interventions such as keeping the call light within reach and orienting the resident to surroundings. On 1/1/26, this resident reported feeling weak while attempting to get to the bathroom and slid to the floor onto their knees. Interviews with the MDS assistant and MDS nurse indicated that the assistant opened required assessments so they would appear on the dashboard, and that nursing staff were responsible for completing fall risk evaluations on admission, quarterly, annually, and after a fall; they were unable to explain why the two quarterly fall risk evaluations were not completed. The DON confirmed that the quarterly fall risk evaluations for both residents should have been completed when due, and the facility’s Falls Management policy directed that a fall risk evaluation be conducted on each resident upon admission, with the quarterly MDS cycle, and when a significant change in status occurs, including a fall.
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