Failure to Document Post-Incident Assessments Following Resident Altercation
Penalty
Summary
The facility failed to ensure that complete and accurate medical records were maintained for two residents following an incident of abuse. Both residents were involved in a physical altercation witnessed by CNAs, during which one resident attempted to sit in an empty chair, leading to a confrontation that escalated to physical contact, including punching, kicking, and grabbing. The incident was documented in incident notes and witness statements, but there was no evidence in the clinical records of a head-to-toe assessment or documentation of any injuries sustained by either resident after the altercation. One resident had a history of anxiety disorder, insomnia, hemiplegia, dysphagia, and other conditions, and was noted to have moderate cognitive impairment. The other resident had diagnoses including altered mental status, cognitive communication deficit, atrial fibrillation, chronic kidney disease, and rhabdomyolysis. Despite the altercation resulting in visible injuries such as bruising, scabs, and skin tears, the clinical records for both residents lacked documentation of assessments or injuries following the incident. Interviews with staff, including an LPN and the DON, confirmed that assessments were performed and injuries were observed, but these were not documented in the residents' medical records. The DON acknowledged that the lack of documentation did not meet expectations for adequate medical record-keeping. Additionally, the facility did not have a policy on documentation in the clinical record, as confirmed by the DON.