Failure to Document Resident Incidents in Medical Records
Penalty
Summary
The facility failed to ensure that resident records were up to date and accurate for three residents. In the first instance, a resident was involved in an incident where he flipped backwards in his wheelchair while being transported in a van and hit his head. This event was confirmed by the resident, his daughter, and the former Maintenance Director, but there was no documentation of the incident in the resident's electronic medical record. The facility's fall prevention and management policy requires documentation of such events, including outcomes, observations, and notifications. In the second case, a resident exited the building through a dining room door and was found outside on the sidewalk. Staff responded to the alarm and brought the resident back inside without injury. The LPN involved stated she was told by the Administrator to hold off on charting, and no documentation of the event was found in the resident's record. The facility's policy requires reporting and documentation of missing residents. In the third case, a resident experienced a malfunction with a sit-to-stand machine during toileting, requiring manual assistance to be safely lowered. The CNA, LPN, and Social Service Director were aware of the incident, but no documentation was made in the resident's record, contrary to the facility's charting and documentation policy.