Failure to Document Change of Condition Monitoring After Fall
Penalty
Summary
The facility failed to ensure that nursing documentation was completed for each shift over a 72-hour period following a resident's change of condition (COC) due to an unwitnessed fall. According to the facility's policies, licensed nurses are required to document each shift for at least 72 hours after a COC, including falls, to monitor for changes in the resident's condition. Medical record review for a resident who experienced an unwitnessed fall revealed that this required documentation was missing for the specified period following the incident. Interviews with nursing staff, including an LVN and an RN, confirmed that the documentation was not completed as required and that the resident was transferred to an acute care hospital before the 72-hour monitoring period was finished. Both staff members acknowledged that the facility's policy mandates shift-by-shift documentation for 72 hours post-fall to monitor for any changes in health status. The Director of Nursing and the Administrator also acknowledged the findings during a review of the medical record.