Failure to Document Unwitnessed Fall and Injuries in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident following an unwitnessed fall. The resident, who had a history of dementia, repeated falls, bone density disorder, and severe cognitive impairment, was found sitting on the floor in another resident's room. Multiple staff members, including CNAs and LPNs, observed and assessed the resident, noting visible injuries such as skin tears on the right forearm and bruising on the left heel. Despite these findings, there was no immediate documentation of the incident or injuries in the resident's electronic medical record (EMR) by the staff who first responded. The care plan for the resident indicated that sitting on the floor was only considered intentional and not a fall if it was witnessed. In this case, the event was unwitnessed, and staff were uncertain whether to classify it as a fall. As a result, required risk management documentation and event reporting were not completed at the time of the incident. The lack of documentation persisted even after subsequent staff discovered and treated the injuries, with some staff expressing confusion about the care plan and reporting requirements. Interviews with staff and review of facility policy confirmed that risk management documentation should have been completed for any unwitnessed fall or skin injury, including skin tears. The omission of this documentation was acknowledged by several staff members, including the DON, who stated that the expected protocol was not followed. The deficiency was identified through observation, interviews, and record review, revealing a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.