Failure to Document Resident Altercations and Assessments in Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents involved in multiple altercations. Specifically, after a reported incident where one resident was pulled from a wheelchair by another, there was no documentation in the medical records of either resident describing the incident or assessing their physical and psychosocial condition. Additionally, there was no record of interventions implemented to protect the residents or the response to those interventions. In a subsequent incident involving the same resident as the aggressor and two other residents as victims, the medical record for one of the victims did not include a description of the incident or an assessment of their condition following the altercation. A third altercation occurred later the same day, resulting in injuries to one resident, but the nursing progress notes again failed to document the incident or the resident's condition immediately after. The only related note appeared the following day, describing the injuries but not the circumstances of the altercation. Staff interviews confirmed that each resident involved in such incidents should have corresponding documentation in their medical records, but no explanation was provided for the lack of progress notes regarding these events.