Failure to Complete Quarterly Fall Risk Evaluation for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that services met professional standards of quality by not completing a required Fall Risk Evaluation at least quarterly for one resident reviewed for falls. The resident had diagnoses including a left scaphoid fracture, weakness, Alzheimer’s disease, and aphasia following a cerebral infarction. A Fall Risk Evaluation dated 10/30/25 identified the resident as not at risk to low fall risk, while the Resident Care Plan dated 11/19/25 documented that the resident was at risk for falls due to new admission status, cognitive impairment, and generalized weakness, with interventions such as keeping the call light within reach, orienting to surroundings, and instructing the resident to ask for assistance before transfers or ambulation. A quarterly MDS assessment later identified severely impaired cognition (BIMS score of 3) and a need for substantial assistance with bed mobility, transfers, and ambulation. Despite these findings, review of the clinical record showed no Fall Risk Evaluation was completed between 10/31/25 and 2/9/26, including around the time of the quarterly MDS. On 2/10/26 at 1:31 AM, an RN documented that the resident had fallen and was found on the floor on the right side, with a reddened right hip but denying pain; vital signs were obtained and the provider was notified, but there were no documented orders for monitoring the reddened hip. Later that day, the DON documented that the resident had sustained a fall and was later noted to have a bump on the right side of the head and inability to move the neck, though still denying pain or discomfort, and the resident was evaluated by an APRN and transferred to the ED. Hospital records showed an admission from 2/10/26 through 2/16/26 for an acute displaced type II odontoid fracture following the fall. The DON stated that all residents should have a Fall Risk Evaluation on admission, quarterly, and with a change in condition, and acknowledged that this resident should have had a Fall Risk Evaluation completed around the time of the quarterly MDS. The facility’s Falls Protocol policy referenced review and documentation of fall risk factors and evaluation of falls, but a specific policy on Fall Risk Evaluations was not available.
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