Incomplete and Inaccurate Medical Records Following Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident with multiple complex diagnoses, including cerebral palsy, epilepsy, abnormal posture, torticollis, and scoliosis. The resident reported that in February, she rolled out of bed while a staff member was providing a bed bath, resulting in pain, difficulty breathing, and subsequent hospitalization for several fractured ribs and a hip fracture. Documentation in the nurse's notes inaccurately described the incident as an unwitnessed fall, rather than reflecting that the fall occurred in the presence of staff during care. Additionally, the certified nursing assistant's statement indicated she was present and momentarily turned away when the resident rolled off the bed. A review of the resident's medical record revealed missing documentation related to the fall, including the facility-to-hospital transfer form and delayed uploading of neurological checks and hospital notes, which were only added to the record several months after the incident. Despite multiple requests during the survey, the facility was unable to provide the required transfer form, and some documentation was not present in the resident's record at the time of review. The facility's process for uploading and maintaining records was inconsistent, resulting in incomplete and inaccurate medical records for the resident.