Incomplete Documentation Following Resident-to-Resident Incident
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurate following an incident involving resident-to-resident physical contact. The incident occurred when one resident, who had diagnoses including cognitive communication deficit, pressure ulcer, laceration, and dementia, was physically struck by his roommate after a verbal disagreement. The event was witnessed by a CNA, who intervened and reported the incident to nursing and administrative staff. However, there was no documentation in the clinical record describing the incident, evidence of monitoring or alert charting, notification to the medical provider, or assessment for injury following the event. Interviews with staff confirmed that the required post-incident assessments and notifications were not documented as per facility policy, which mandates that all services, changes in condition, and notifications be recorded in the resident's medical record. The Director of Nursing acknowledged that the initiation of 15-minute checks was missed and that documentation of assessments and notifications should have been completed in the risk management and progress notes. The lack of documentation could result in care team members being unaware of the resident's status and missing or delaying necessary treatment.