Incomplete Documentation of Resident Fall Incident
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for a resident, identified as Resident 3, who was involved in a fall incident. According to the facility's policy on accidents and incidents, falls require an incident report to be completed within 24 hours, including documentation of the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and follow-up interventions. However, a review of Resident 3's clinical record revealed no documented evidence of the fall or an assessment by a registered nurse, despite the fall investigation conducted by a Licensed Practical Nurse (LPN) indicating that the resident fell backwards onto her buttocks in the bathroom doorway. Resident 3, who was severely cognitively impaired with diagnoses including Alzheimer's disease and wandering behaviors, required supervision and assistance with various activities of daily living. The LPN involved in the fall investigation confirmed that she and the registered nurse on duty assessed Resident 3 following the fall but did not document an additional nursing note in the clinical record. The Director of Nursing also confirmed the absence of documentation regarding the fall and the necessary assessment by a registered nurse, which was required by the facility's policy.
Plan Of Correction
Resident 3 suffered no ill effects as a result of failure to document the incident and accident or failure to conduct the Registered Nurse assessment. Education for Registered Nurses and Licensed Practical Nurses will be conducted on 1/14/2025 regarding documentation of the incidents and accidents and documentation of the Registered Nurse assessment. Review of change in condition will occur during the clinical portion of the Interdisciplinary Team meeting to ensure documentation of incidents and accidents and the registered nurse assessments occurred appropriately and timely. Weekly audits for accuracy by the Director of Nursing or designee will be conducted weekly, and the results of these audits will be reviewed at Quality Assurance and Process Improvement meetings until substantial compliance is achieved.