Failure to Document Allegation of Sexual Abuse in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, there was no documentation in the resident's progress notes or 24-hour reports regarding an allegation of sexual abuse made by the resident. The resident, who had vascular dementia, hypertension, hemiplegia, hemiparesis, and lack of coordination, reported being inappropriately touched by a CNA during a shower. Although the resident initially did not report the incident due to embarrassment, he later informed facility staff. Interviews with staff revealed that the allegation was communicated among staff members, but none of the involved staff documented the incident in the resident's medical record or facility reports. The facility's own documentation policy requires that all observations, investigations, and communications involving resident care and treatments be recorded accurately and completely in the clinical record. Despite this, neither the nursing staff nor the interdisciplinary team ensured that the allegation was documented. The administrator confirmed that there was no documentation of the event, statements, or incident reports related to the allegation, emphasizing the importance of such documentation for continuity of care.