Failure to Complete Required Post-Fall Assessment and Documentation
Penalty
Summary
The facility failed to ensure the medical record for one resident was complete and accurately documented, as required by its own policy and procedure. After a resident experienced a fall, the required Post-Fall Assessment & Investigation was not completed or documented in the resident's medical record. The resident, who had diagnoses including atrial fibrillation, congestive heart failure, and diabetes mellitus type 2, reported falling while attempting to steady herself after leaving the bathroom. The fall was witnessed by her roommate, who sought staff assistance. Staff interviews confirmed that, although the facility's policy mandates a Post-Fall Assessment & Investigation following any resident fall, this documentation was not completed for the incident in question. Review of the resident's care plan and medical record showed that the Post-Fall Assessment & Investigation template was created in the electronic record but left incomplete. Both the Assistant Director of Nursing and the Director of Nursing acknowledged that the assessment should have been completed by a registered nurse shortly after the incident, but it was not done. The facility's policy specifically requires this documentation to be maintained in the resident's medical record following a fall, and the failure to do so resulted in an incomplete record for the resident involved.