Failure to Maintain Accurate Medical Record After Resident Fall
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident who experienced a fall. According to the facility's policies, neurological assessments are required after a head injury or as ordered by a physician, and these assessments must be documented in the resident's medical record. The resident, who had severe cognitive impairment, fell and sustained a head injury, resulting in hospitalization and subsequent return with stitches and bruising. Although neurological assessments were documented in the electronic record, the Director of Nursing later confirmed that these entries were transcribed from a paper form completed by an agency RN, and the original documentation could not be located. No additional documentation for the neurological assessments was available.