F0689

D

Inaccurate Fall Risk Evaluations for Two Residents

Reseda, California Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to accurately complete fall risk evaluations for two residents, contrary to its policy for promoting safety and reducing falls. For the first resident, who had diagnoses including acute on chronic diastolic CHF, chronic pulmonary edema, and orthostatic hypotension, the admission record showed readmission on 12/30/2025 and an MDS indicating intact cognition and dependence on staff for ADLs. The Fall Risk Evaluation dated 12/30/2025 documented that there was “no noted drop between lying and standing” for systolic blood pressure, even though the resident was not able to stand. The gait/balance section was left entirely unmarked, including the option for “not able to perform function,” and the medications section was also left blank, including the option indicating no relevant medications. The resulting fall score was four, which did not place the resident in the high-risk category.

During interview and concurrent record review, the RN who completed this evaluation stated that the resident was not able to stand at the time of the assessment. The RN acknowledged marking “no noted drop between lying and standing” for systolic blood pressure because there was no “non-applicable” option, and admitted not completing the gait/balance and medication sections. The RN further stated that the total score of four, indicating no risk of fall, was not correct and confirmed that assessments are used to establish the plan of care to reduce fall risks. These statements confirmed that the fall risk evaluation for this resident was not completed thoroughly or accurately as required by the facility’s process.

For the second resident, who had combined systolic and diastolic CHF and hypertension, the admission record showed readmission on 12/29/2020 and an MDS indicating intact cognition, with moderate assistance needed for oral/personal hygiene and supervision or touching assistance for toileting hygiene, dressing, and toilet transfer. The Fall Risk Evaluation dated 12/22/2025 recorded the resident as ambulatory and continent and again indicated “no noted drop between lying and standing” for systolic blood pressure, resulting in a fall score of eight, which did not meet the facility’s threshold for high fall risk. In an interview, the resident reported sometimes going to the bathroom alone and being able to self-clean. During a concurrent interview and record review, the MDS nurse who completed the evaluation stated she did not measure the resident’s systolic blood pressure in both lying and standing positions and instead relied on blood pressure summaries from other nurses, which did not include standing readings. She acknowledged that, as a result, the fall risk evaluation was not done correctly to assess the resident’s fall risks. The facility’s policy on promoting safety and reducing falls emphasized the need for caregivers to understand key fall risk factors, including gait and balance disturbances and the importance of residents rising slowly from lying or sitting positions, underscoring the expectation for accurate assessment of these parameters.