Incomplete Medical Record Documentation Following Resident Fall and Hospital Transfer
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted following orthopedic surgery for rehabilitation and later discharged. Review of the resident's medical record revealed a lack of documentation regarding a fall and subsequent transfer to the hospital on the day of discharge. The last nurse's note and evaluation prior to the incident was recorded the previous day, and the only note on the day of the fall referenced a call from the resident's representative about the hospital transfer, with no nursing assessment or discharge information related to the fall documented. The Director of Nursing confirmed that the required nurse's notes, assessments, and discharge information were missing from the resident's medical record.