Failure to Maintain Complete and Accurate Medical Records After Resident-to-Resident Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents following incidents of inappropriate touching. For one resident with diagnoses including Parkinson's, dementia, anxiety, and depression, interdisciplinary notes referenced inappropriate behavior but did not specify the nature of the behaviors, who was affected, or what interventions were implemented. There was also no documentation that the resident was placed on 15-minute checks as ordered, nor was there evidence that these checks were completed after the care plan was updated. Additionally, a psychiatric nurse practitioner's note did not reflect awareness of the incident or changes in medication related to observed behaviors. For the second resident, who had Lewy body dementia with psychotic disturbance, major depressive disorder, and anxiety, the records did not document the incident of inappropriate touching, notification to the physician or family, or immediate skin assessment to check for injury. There was also no documentation of how the resident was kept safe following the incident or how interventions were implemented to prevent further occurrences. The hospice visit note referenced the incident but did not specify how the other resident was restricted from entering rooms. Neither resident's clinical record included documentation that the DON and Unit Manager had reviewed the incident to confirm no sexual contact occurred, nor did the records indicate that families were notified or that interventions were put in place to ensure resident safety. The facility's policy requires timely and accurate documentation of all assessments, observations, and services, but this was not followed in these cases.