Failure to Document Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident, as required by professional standards of practice. The resident, who had a medical history of hypertension and type 2 diabetes, experienced a fall in the shower room when a shower chair collapsed. Although the resident sustained scratches and later reported head pain and nausea, prompting a transfer to the hospital, the facility did not document the fall, the assessments conducted, the injuries sustained, or the time of hospital transfer in the clinical records. Additionally, there was no documentation indicating that the resident's physician was notified of the incident. The deficiency was confirmed through a review of facility investigative reports, clinical records, and staff interviews. The Nursing Home Administrator and Director of Nursing acknowledged that the nursing staff failed to document consistently and accurately in the resident's clinical records, resulting in inaccuracies and incompleteness. This failure to document critical information contravenes the American Nurses Association Principles for Nursing Documentation and the Title 49 Professional and Vocational Standards, which mandate timely and accurate record-keeping to ensure high-quality care and informed decision-making by the healthcare team.
Plan Of Correction
1. Staff involved with resident #1 fall were educated on accurate documentation; a late entry note was placed into the chart. 2. A 14-day look back of falls will be completed to ensure the timely documentation/assessments were completed. Policy reviewed and revised. 3. The nurse educator will educate current LN's on the revised fall policy for post-fall documentation and assessment. 4. The DON/designee will review all falls in clinical stand up 5 times a week for 4 weeks, with results to QAPI.