Failure to Timely Document Resident's Unwitnessed Fall
Penalty
Summary
The facility failed to ensure timely documentation for a resident, identified as Resident R24, after an unwitnessed fall occurred. The facility's policy on 'Charting and Documentation' requires that all services provided, progress toward care plan goals, and any changes in a resident's condition be documented in the medical record to facilitate communication among the interdisciplinary team. However, multiple late entry progress notes were made by various staff members, including Registered Nurses and Licensed Practical Nurses, after the resident's time of death was called. These notes detailed the circumstances of the fall and the resident's condition but were not entered in a timely manner as required by the facility's policy. Resident R24 had a medical history that included diabetes, renal insufficiency, and dementia. The incident report indicated that the resident had an unwitnessed fall, and subsequent documentation was delayed. Interviews with staff members confirmed the failure to document the incident promptly. The Nursing Home Administrator also acknowledged the deficiency in ensuring timely documentation for the resident after the fall, which was a requirement under the facility's policies and professional standards of quality.
Plan Of Correction
Resident R 24 no longer resides at the facility. Employees E1, E2, and E5 were re-educated by the Director of Nursing (DON) on ensuring documentation is entered timely. A look back of 7 days of progress notes on all falls will be conducted by the Director of Nursing/ designee with any corrective action upon discovery. DON/ designee will re-educate all licensed nurses on the importance of timely documentation with each risk management. DON/designee will monitor progress notes 5x per week x2 weeks and 3x per week x2 weeks to ensure notes are put in timely after falls and risk management is complete and accurate.