F0689

E

Failure to Complete Fall Risk Assessments, Post‑Fall Follow‑Ups, and Neuro Checks

Camilla, Georgia Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its Falls and Falls Risk Management policy by not consistently completing fall risk assessments, 3‑day post‑fall follow‑ups, and neurological checks for four residents with documented falls. The policy requires staff, with physician input, to identify interventions based on evaluations and current data, and to monitor and document each resident’s response to interventions intended to reduce falls and fall risk. However, for multiple residents with diagnoses such as Alzheimer’s disease, dementia, cerebral infarction, hemiplegia, and unsteadiness on feet, the required assessments and monitoring were either missing or incomplete.

One resident with Alzheimer’s disease, dementia, diabetes, and unsteadiness on feet experienced multiple unwitnessed falls in the hallway and in her room. Nursing notes documented falls on several dates, including one with redness to the left foot and a skin tear to the left elbow, but there was no evidence of any 3‑day post‑fall follow‑up for these events. Neurological checks initiated after one unwitnessed fall were incomplete and did not follow the required timing protocol, and there was no evidence of any fall risk assessments in the medical record despite a physical therapy assessment identifying the resident as a fall risk. Another resident with cerebral infarction, hemiplegia, hypertension, adult failure to thrive, and chronic pain had multiple unwitnessed falls in his room and bathroom. For these falls, neurological checks were incomplete and not done per timing protocol, and 3‑day post‑fall follow‑ups were not completed. Fall risk assessments were only documented in early 2023, with no evidence of updated assessments for 2024 and 2025.

A third resident with palliative care needs, cerebral infarction, hypertension, and dysphasia had a witnessed fall documented in nursing notes, but there was no evidence of a 3‑day post‑fall follow‑up. An LPN confirmed that after a fall, a 3‑day post‑fall follow‑up should have been completed and that fall risk assessments were expected on admission and with monthly summaries, as well as neurological checks for unwitnessed falls or head injuries. A fourth resident with Alzheimer’s disease, dementia, and hypertension had unwitnessed falls documented in nursing notes, including one where a roommate called for help. Although the RN reported assessing the resident, obtaining vital signs, and documenting follow‑up under a fall charting tab, there was no evidence of a complete 3‑day post‑fall follow‑up for one of the falls, and neurological checks were incomplete and not done according to the required timing protocol. The care plan listed a fall but lacked additional documentation related to that fall. The DON and Administrator acknowledged expectations that assessments and neurological checks be completed per the fall policy and noted issues with the electronic medical record not triggering required follow‑ups and not allowing neuro checks to be completed electronically.