Failure to Complete Required Post-Fall Assessments and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to complete required post-fall assessments, including vital signs, head-to-toe assessments, and fall follow-up documentation, for two residents with severe cognitive impairment and histories of falls. One resident, admitted with diagnoses including adult failure to thrive, unspecified lack of coordination, and weakness, had a witnessed fall from bed on 10/8/25 with no further assessments documented related to that fall. On 11/3/25, this resident was again found on the floor at bedside with a fall mat in place and reported rolling over in bed; the risk management report documented the event, but there were no follow-up assessments in the progress notes for 11/4/25, and the post-fall assessment dated 11/5/25 only included vital signs taken on 11/3/25. On 1/2/26, the same resident fell forward from bed, striking his face on a nightstand, was sent to the ER, and returned with sutures to the bridge of his nose. Aside from a follow-up assessment of the nose laceration on 1/3/26, there were no further assessments or vital signs documented related to this fall. The second resident, admitted with a history of falling and diagnoses including dementia and bipolar disorder, had an unwitnessed fall in her room on 12/17/25, during which she reported hitting her face/head on the floor and was sent to the ER for evaluation. After her return, the progress notes contained no follow-up assessments related to this fall during the 72 hours following the incident. Interviews with an RN and the DON confirmed that facility practice and the post-fall tool require neuro checks for all falls, documentation of whether the fall was witnessed or unwitnessed, skin and physical assessments, pain assessments, full sets of vital signs, and monitoring every shift for 72 hours, with all information charted in the notes. The facility’s fall risk tool also specifies change-of-condition charting every shift for 72 hours, including full vital signs and, if skilled, a head-to-toe assessment and fall follow-up, which were not completed as required for these two residents.
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