Incomplete Documentation of Resident Fall in Medical Record
Penalty
Summary
A deficiency occurred when a Licensed Vocational Nurse (LVN) failed to document the details of a resident's fall in the medical record. The resident, who had diagnoses including hemiplegia, hemiparesis following cerebrovascular disease, dementia, and Alzheimer's disease, was severely cognitively impaired and dependent on staff for most activities of daily living. The facility's records indicated that the resident had experienced multiple falls, with the most recent incidents occurring on consecutive days. On the date in question, the LVN was informed by a Certified Nursing Assistant (CNA) that the resident had fallen, and upon assessment, found the resident lying on the floor beside the bed. Despite the incident being recorded in the facility's risk management system, the LVN did not document the fall or the surrounding circumstances in the resident's progress notes, as required by facility policy. The Change in Condition Evaluation noted the occurrence of the fall but lacked pertinent details about the event. The Director of Nursing (DON) and a Registered Nurse (RN) confirmed that the fall should have been documented in the resident's medical record to ensure the healthcare team was aware of the resident's status. The facility's policy specified that licensed nurses must document the date, time, and relevant details of such incidents in the nursing notes, which was not done in this case.