F0842

D

Incomplete Fall Risk Assessments and Inaccurate Nursing Documentation

Mission Hills, California Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident by not fully completing required Fall Risk Assessments. The resident had been originally admitted in 2019 and readmitted in 2025 with multiple diagnoses, including chronic diastolic CHF, a right shoulder rotator cuff tear or rupture, wedge compression fracture of T11–T12 vertebra, and muscle weakness. A History and Physical dated 7/1/2025 documented that the resident had the capacity to understand and make decisions, and an MDS dated 1/21/2026 indicated intact cognitive functioning. The MDS further showed the resident was dependent on staff for toileting hygiene, showers, and lower body dressing, and required maximal assistance for bed mobility, transfers between lying and sitting, upper body dressing, and personal hygiene.

During an interview and concurrent record review with an RN on 2/18/2026, Fall Risk Assessments dated 7/29/2025, 10/1/2025, and 10/22/2025 were reviewed and found to have section F, which assesses systolic blood pressure variation when changing positions between lying and standing, left unassessed. The RN acknowledged that the Fall Risk Assessments for July and October 2025 were incomplete and stated that the assessments did not correctly describe the resident’s condition, which could potentially lead to a lower score level and affect the resident’s care, leading to a higher risk for falls. The facility’s policy on Nursing Documentation, last reviewed on 1/26/2026, required nursing documentation to be concise, clear, pertinent, and accurate, and described expectations for alert charting to accurately describe the resident’s condition and the nursing response, which was not met in the incomplete fall risk documentation for this resident.