Failure to Document Resident Incident in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was left outside overnight. Although the incident was documented on a concern form and a handwritten note, it was not entered into the resident's electronic health record (EHR) as required by professional standards and facility policy. Staff members reported being directed by administration to document the incident only on a concern form and not in the clinical record, despite expressing discomfort with this approach. The resident involved was cognitively intact, had a history of non-Alzheimer's dementia, anxiety, depression, and dizziness, and was independent with activities of daily living. The incident involved the resident being unable to re-enter the facility after being outside, resulting in her remaining outside all night. Upon discovery, the resident was assessed and found to have no injuries or acute medical issues. The lack of documentation in the EHR meant that the incident, the resident's condition, and the follow-up actions were not properly recorded in accordance with accepted professional standards and facility policy, which requires all incidents and changes in resident status to be documented in the clinical record.