Failure to Document Resident Fall and Required Notifications in Clinical Record
Penalty
Summary
The facility failed to ensure that a resident's fall, as well as the notifications to the physician and responsible party, were properly documented in the clinical record. The resident involved had diagnoses including diabetes with foot ulcer, repeated falls, and dementia, and was assessed as severely cognitively impaired, requiring substantial assistance with daily activities. Although a fall incident report was completed and maintained in risk management, this documentation was not included in the resident's clinical record. The incident report detailed that the resident fell forward out of a wheelchair while reaching for a dropped fork, with no injuries noted, and that the family and DON were notified. However, there was no documentation in the clinical record on the day of the fall regarding the incident or the notifications made. A subsequent health status note referenced the fall but was written the day after the event, based on information from the unit manager. The facility's policy required documentation of the fall, notification of the physician and responsible party, completion of an incident report, and detailed progress notes in the medical record, including the resident's condition every shift for 72 hours. The DON acknowledged that it was best practice to document falls in the clinical record and that risk management notes were sometimes copied into progress notes, but this was not done in this case.