Failure to Maintain Accurate Medical Records Following Resident Fall
Penalty
Summary
The facility failed to maintain medical records in accordance with professional standards of quality for one of seven facility-reported incidents reviewed during a complaint survey. Specifically, after a resident experienced an unwitnessed fall resulting in a left wrist fracture, the facility's investigation file contained two duplicate handwritten documents from the consultant orthopedic Physician Assistant. One document indicated the right wrist was affected, while the other indicated the left wrist, with both otherwise being identical. The presence of these conflicting documents created confusion regarding the accurate medical record for the resident's injury. Interviews with the DON and the Physician Assistant revealed uncertainty about who altered the documentation to correct the affected wrist from right to left. The DON acknowledged that the facility accepted and filed the document with the correction, despite not knowing who made the change. The Physician Assistant stated he did not amend the document or write an addendum in this case. The DON confirmed that the document was incorrectly amended and that this constituted a deficiency in maintaining accurate medical records.