Failure to Document Post-Fall Monitoring for a Resident
Penalty
Summary
The facility failed to ensure that the medical record for one resident was accurate and complete following a fall incident. Specifically, after an unwitnessed fall with no evidence of injury, the required documentation of the resident's condition monitoring every shift for 72 hours was not completed. The facility's policy required licensed nurses to record information related to changes in a resident's condition and to continue monitoring and documenting the resident's status every shift for 72 hours after such an event. However, a review of the resident's progress notes revealed missing documentation for several shifts during the required monitoring period. Interviews with nursing staff confirmed that the expectation was to assess and document the resident's condition every shift for 72 hours post-fall. Both RN 3 and RN 4 acknowledged that the necessary documentation was not present in the medical record, and the DON verified these findings. The resident involved had no capacity to understand or make decisions, as noted in their medical history, further emphasizing the importance of thorough monitoring and documentation after the fall.