Incomplete Medical Record Following Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident following an unwitnessed fall. Specifically, after a resident experienced an unwitnessed fall, surveyors requested the fall investigation report from the Director of Nursing (DON). The DON was unable to locate the original report and instead recreated the documentation on a new form, which was dated several months after the incident. The DON confirmed that the original document could not be found, resulting in incomplete records for the resident involved in the fall. This deficiency was identified through clinical record review and staff interviews, and it was determined that the facility did not adhere to accepted professional standards for maintaining resident medical records as required by state regulations.