Failure to Complete Admission Fall Risk Evaluation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Guideline Policy by not completing a Fall Risk Evaluation upon admission for a newly admitted resident. The resident, an older female with multiple diagnoses including COPD with acute exacerbation, acute respiratory failure with hypercapnia, type 2 diabetes mellitus, asthma with acute exacerbation, epilepsy with status epilepticus, chronic fatigue, history of falling, lack of coordination, altered mental status, abnormal EEG, supraventricular tachycardia, and hypertension, was admitted on 6/5/2025 and discharged on 6/6/2025. The facility’s policy, revised 8/2024, requires that a fall risk evaluation be completed upon admission, quarterly, annually, and with significant change in condition, and that if the evaluation finds the resident at risk, resident-specific interventions and precautions are implemented. The Restorative Director, the admitting LPN, and the DON all confirmed through interview that the admitting nurse is responsible for completing the initial fall risk assessment on the day of admission and that no such assessment was found for this resident on the admission date. During the resident’s short stay, two falls were documented. On 6/5/2025 at 3:15 PM, an incident report completed by the admitting LPN documented that the resident was found sitting on the floor in her room after stating she needed to go to the bathroom and had not used the call light because she forgot and urgently needed to use the bathroom. On 6/6/2025 at 1:00 PM, another incident report documented that the resident was observed on the floor after an unwitnessed fall, with a knot noted on the left side of the head and no active bleeding; the resident reported she had been sitting in her wheelchair, reached down to grab her phone, and lost her balance. A Fall Risk Observation completed later on 6/6/2025 at 2:56 PM categorized the resident as high risk for falls with a score of 13. Staff interviews confirmed that the initial fall risk evaluation, which should have been completed upon admission, was not done, and that failure to complete this assessment places a resident at risk of falling.
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