Failure to Complete Fall Documentation and Post-Fall Assessments for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and management policy for two high fall-risk residents by not completing required fall risk evaluations and post-fall assessments, and by failing to document at least one fall event. One resident, a male with acute respiratory failure, tracheostomy, schizoaffective disorder, and epilepsy, had multiple fall risk assessments with scores greater than 10, indicating high risk for falls. His fall risk scores included 15, 13, 25, 25, and 23 on various dates. A progress note documented that he rolled out of bed and was sent to a local hospital for evaluation, but there were no fall or pain assessments completed after this fall, despite the facility policy requiring a fall risk evaluation after each fall. The second resident, a male with hemiplegia, hemiparesis, diabetes, vascular dementia with anxiety, and tracheostomy, also had multiple fall risk assessments with scores greater than 10, indicating high risk for falls, including scores of 14, 22, 24, and 22. A progress note documented that he was found sitting on his buttocks on a floor mat next to the bed and was sent to a local hospital for evaluation. The DON stated there was no completed fall report for this fall and no documented post-fall assessments for falls on two separate dates. The restorative nurse confirmed that the nurse documented the resident on the floor but did not complete a fall report, risk management, or fall assessment. The Administrator and DON both stated their expectation that staff complete risk management, fall assessments, and required documentation after every fall, consistent with the facility’s Fall Prevention and Management policy, which requires a fall risk evaluation on admission, readmission, quarterly, and after each fall, and completion of a fall incident report in the risk management portal.
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