Falls are the leading cause of injury in RCFEs and a top CDSS inspection deficiency. This policy provides a scored risk assessment tool, tiered prevention measures, and a complete 9-step post-fall response protocol.
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CCR §87463 requires RCFEs to assess and address each resident's functional capabilities and safety needs, including fall risk. CCR §87211 requires incident documentation. CCR §87625 covers reporting serious injuries to CDSS. Falls are among the most frequently cited deficiencies during CDSS inspections.
A scored fall risk assessment assigns numerical values to fall risk factors (mobility impairment, medication effects, cognitive status, fall history, etc.) and produces a total score that determines the level of prevention intervention required: standard, enhanced, or intensive monitoring.
Under CCR §87211, any incident resulting in a serious injury - defined as requiring emergency medical treatment, hospitalization, or resulting in permanent injury - must be reported to CDSS within 24 hours. The report must document the circumstances, immediate response, and corrective actions taken.
The 9-step protocol in this policy covers: (1) do not move the resident, (2) call for help, (3) assess for injury, (4) call 911 if injury is suspected, (5) notify the administrator, (6) notify the physician and responsible party, (7) complete an incident report, (8) update the care plan, (9) conduct a root cause review within 72 hours.
Fall risk assessments should be completed at admission, after any fall, after any change in the resident's condition or medication regimen, and at least every six months as part of the routine care plan review.