Failure to Accurately Assess Fall Risk and Complete Post-Fall Neuro Checks
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident at risk for falls was properly assessed and monitored after fall events, in accordance with its own fall-related policies and procedures. Resident 8 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, abnormalities of gait and mobility, and a history of falling. An MDS dated 1/15/2026 documented mildly impaired cognitive skills for daily decisions and a need for moderate to supervision assistance with ADLs, as well as use of a manual wheelchair. The resident’s fall risk care plan, initiated on 7/17/2025, identified problems and concerns related to falls and potential for injury due to balance issues, cognitive and physical impairment, generalized weakness, lack of coordination, and hemiparesis/hemiplegia, with interventions such as maintaining a hazard-free environment, keeping the call light and frequently used items within reach, and providing assistance with transfers. The facility’s fall risk evaluations for Resident 8 showed inconsistent and inaccurate scoring relative to the resident’s condition and history. A fall risk evaluation dated 10/22/2019 showed a high fall risk score of 11, while the evaluation dated 1/16/2026 showed a moderate fall risk score of 8, and the evaluation dated 2/17/2026 again showed a high fall risk score of 13. During interview and record review, RN 1 acknowledged that the 1/16/2026 fall risk evaluation was not accurately documented: the item for history of falls in the past three months was scored as 0 (no falls), despite facility records indicating a history of falls, and the gait/balance section was left blank instead of reflecting multiple balance and gait problems and the need for assistive devices. These inaccuracies meant the documented fall risk score did not accurately reflect the resident’s true fall risk status. The facility also failed to complete and document required 72-hour post-fall neurological checks after Resident 8 slipped out of the wheelchair during a transfer on 1/16/2026 and was later found on the floor on 2/17/2026. Review of the 72-hour neuro check documentation showed that post-fall neuro assessments were only recorded on 1/17/2026 during the 7 a.m.–3 p.m. shift and on 1/19/2026 during the 11 p.m.–7 a.m. shift, with no neuro checks documented on the evening and night shifts of 1/16/2026, the evening and night shifts of 1/17/2026, or on any shift on 1/18/2026. RN 1 stated that, per facility practice, residents must be checked by licensed nurses on all three shifts for 72 hours after a fall, and the DON confirmed there were inconsistencies and incomplete documentation of the post-fall assessments and fall risk evaluations. These actions and omissions constituted a failure to follow the facility’s policies titled “Falls by a Resident” and “Fall Risk & Prevention of Injury to include pathological Fractures,” which require complete post-fall assessments, incident investigations, and accurate fall risk assessments to guide care planning.
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