Failure to Accurately Update Fall Risk Evaluation After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to accurately update and complete a fall risk evaluation for a resident following an unwitnessed fall. The resident was admitted with multiple fractures of the left tibia, difficulty walking, and pain related to internal orthopedic prosthetic devices, implants, and grafts. An H&P documented that the resident had the capacity to understand and make decisions, and an MDS showed the resident required varying levels of assistance with ADLs, including dependence for footwear and lower body dressing and substantial assistance for toileting and showering. On 12/10/2025 at 3:43 a.m., a Change of Condition evaluation documented that the resident experienced an unwitnessed fall. Despite this fall, the Fall Risk Evaluation completed on 12/10/2025 recorded a fall risk score of 6 and indicated that the resident had no falls in the last three months. A subsequent Fall Risk Evaluation dated 12/14/2025, after the resident’s transfer to and return from the hospital, showed a fall risk score of 9 but again documented that the resident had no falls in the last three months. During an interview and concurrent record review, the DON confirmed that the resident had a fall on 12/10/2025 and acknowledged that both Fall Risk Evaluations should have reflected this fall and a higher score, and that inaccurate documentation on the Fall Risk Evaluation would result in the facility not implementing proper fall-prevention interventions. The facility’s Fall Management Program policy stated its purpose was to reduce the risk of avoidable falls and fall-related injuries and to ensure timely, evidence-based post-fall evaluation and management.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.