F0689

D

Failure to Complete Required Quarterly Fall Risk Evaluation for High-Risk Resident

Enid, Oklahoma Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The facility failed to complete required quarterly fall risk evaluations for one resident identified as high risk for falls. The facility’s Fall Prevention Policy, revised 02/2014, required a fall risk evaluation to be completed quarterly, annually, on re-admission, and with significant change in condition. A fall risk evaluation for Resident #3 dated 08/22/24 showed a fall risk score of 11, indicating a high risk for falls, but there was no documentation that any additional fall risk evaluation was completed for this resident between September 2024 and February 2025, despite the facility’s process, as described by the DON, to evaluate residents at admission, quarterly, and upon significant change. During this period, a quarterly resident assessment dated 02/11/25 documented that the resident had heart failure, hypertension, and severely impaired cognition with a BIMS score of 06, and the care plan revised 02/12/25 identified the resident as at risk for falls related to weakness, knee buckling, and hypertension. A Fall Investigation Form dated 02/12/25 showed the resident experienced a fall during transfer. In interview, the ADON confirmed that a quarterly fall risk evaluation had been completed on 08/22/24 and the vice president stated the next evaluation should have been completed in 11/2024, but it was not documented as done.