Failure to Maintain Complete and Accurate Medical Record After Resident Fall
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident following a fall in the shower room. The resident, who had no cognitive impairment and was assessed as high risk for falls, experienced a fall during a transfer in the shower room. The fall was documented in the facility's fall incident log and a fall investigation report, but there was no corresponding documentation in the resident's medical record. The care plan was not updated with an intervention for the fall until more than two months later, during the survey. The resident confirmed the fall and described circumstances that differed from the staff account, including the staff member's distance at the time of the incident and the condition of the shower area. Interviews with facility staff, including the DON and Regional Director of Operations, confirmed the absence of required documentation in the resident's chart, such as the initial incident report and follow-up nursing assessments. The facility's own policy requires immediate investigation, documentation, and follow-up charting for 72 hours after an incident, as well as timely updates to the care plan. These procedures were not followed, resulting in incomplete and inaccurate medical records for the resident after the fall.