Incomplete and Inaccurate Post-Fall Risk Assessment
Penalty
Summary
The deficiency involves the facility’s failure to follow its fall prevention and management policy and to ensure accurate and complete fall risk assessments for a resident reviewed for falls. For one resident (R4), a post-fall risk assessment dated 1/2/26 was incomplete because section G, which addresses falls, accidents, and fractures, was left blank. Specifically, the item asking whether there was a history of falls and/or fracture in the past six months, including the current fall incident, was not selected, even though the assessment was conducted after a fall and should have included the current incident. As a result, the resident’s fall risk score was documented as 7 (at risk) instead of 17 (high risk), as later acknowledged by the DON when interviewed by the surveyor. The facility’s fall prevention and management policy, reviewed in March 2026, requires that a fall risk evaluation be completed on admission, readmission, quarterly, with significant change, and after each fall, but this post-fall assessment was not accurately completed in accordance with that policy. The surveyor’s interview with the DON confirmed that leaving section G unchecked would alter the calculated score and that the correct score, if accurately assessed, should have been 17, which would classify the resident as high risk for falls. This demonstrates that the resident’s post-fall risk assessment was both incomplete and inaccurate, directly contradicting the facility’s stated procedures for identifying and evaluating residents at risk for falls.
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