Failure to Complete Required Post-Fall Assessment and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to follow its Fall Prevention and Management Policy by not completing a required post-fall assessment and documentation for one resident after a fall. Record review showed that the resident’s Fall Event dated 3-16-25 remained marked as “In Progress” with no information entered. The Restorative Nurse stated that this event occurred before she assumed her role and that she had no knowledge of the incident, explaining that the nurse on duty is responsible for completing the Fall Event form. The DON reported that the nurse on duty at the time of the fall was an agency nurse who did not complete the Fall Event form and did not enter any new interventions. Although the fall team completed a soft copy Fall Event form and decided to continue current interventions, they did not enter the form into the computer because the DON was not the nurse on duty at the time, and the intervention date was not updated. As a result, the resident’s Fall Event dated 3-16-25 was not completed as required by the facility’s Fall Prevention and Management Policy, which calls for post-fall observation, assessment of the cause of the fall and potential for injury, and a physical assessment including head-to-toe assessment, vital signs, range of motion, and neurological assessment as indicated. This failure affected one resident out of three reviewed for falls in a total sample of 31 residents, and was identified through interviews with staff and review of the resident’s fall documentation and the facility’s policy.
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