Incomplete and Inaccurate Documentation of Resident Care and Incident Response
Penalty
Summary
The facility failed to ensure complete and accurate documentation in the clinical records for two residents, specifically regarding falls, abnormal vital signs, and changes in condition. For one resident with congestive heart failure, the clinical record showed an episode of abnormal low blood pressure and high heart rate, but lacked documentation of a rechecked blood pressure or physician notification. Although the administrator stated that a second set of vitals was obtained and found to be normal, there was no documentation to support this, and the information could not be provided upon request. Facility policies required timely and complete documentation of assessments, interventions, and notifications, which was not followed in this instance. For another resident with Alzheimer's Disease and a history of falls, the clinical record did not contain documentation that the physician and resident representative were notified of two separate falls, nor was there evidence of an assessment after one of the falls until the following morning. Additionally, a fall prevention intervention to keep the resident's door open for visualization was not consistently implemented, as the door was observed closed on multiple occasions. The care plan was not updated to reflect the resident's preference for a closed door, and discussions with the resident representative regarding this change were not documented in the clinical record. Risk management reports indicated that assessments and notifications were completed at the time of the incidents, but these reports were not part of the official medical record. The facility's documentation policies required that all relevant information be entered into the clinical record, but this was not done, resulting in incomplete and inaccurate records for both residents.