Incomplete and Inaccurate Medical Record Documentation After Multiple Falls
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurate, as required by accepted professional standards. The resident, who had a history of Parkinson's disease, traumatic brain injury, dementia, abnormal gait, cognitive communication deficit, anxiety disorder, and required assistance with personal care, experienced multiple falls and changes in condition during their admission. Despite these incidents, there were significant gaps in the documentation, including missing neuro check logs, incomplete progress notes, and lack of evidence that notifications to the medical provider and family were made after several falls and changes in condition. Specific events included the resident being found on the floor multiple times, attempting to ambulate without assistance, and exhibiting confusion and forgetfulness. On several occasions, the resident was observed to have fallen or attempted to get out of bed or a wheelchair, sometimes resulting in injuries such as a skin tear or the removal of a Foley catheter with the balloon still inflated. Despite these incidents, the medical record often lacked documentation of assessments, neuro checks, and notifications to the provider and family, as required by facility policy and standard practice. Interviews with nursing staff and the Director of Nursing confirmed that the expected protocol after a fall includes assessment, documentation in the medical record, completion of an incident report, and notification of the provider and family. Review of the facility's documentation policy further emphasized the need for complete and accurate records, including details of care provided, assessments, and notifications. However, the review of the resident's clinical record revealed multiple instances where these requirements were not met, leading to incomplete and inaccurate documentation of the resident's care and condition.