Inaccurate Fall Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical record, specifically regarding documentation of falls. According to the facility's policies, nursing staff are required to identify and document resident risk factors for falls and maintain complete and accurate records. For one resident, the medical record review showed a discrepancy: although the resident experienced an unwitnessed fall, the Fall Risk Assessment form indicated that there had been no falls in the past three months. This was inconsistent with other documentation, such as the SBAR Communication Form, which recorded the fall. During interviews, both a registered nurse and the Director of Nursing confirmed the inaccuracy in the Fall Risk Assessment. They acknowledged that the assessment should have reflected the fall by indicating one to two falls in the past three months, rather than none. The failure to accurately document the fall in the resident's assessment resulted in an incomplete and inaccurate medical record, contrary to the facility's own policies and accepted professional standards.