Failure to Document Abuse Allegation and Assessment in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident following an allegation of abuse. Specifically, after a resident reported to their representative that a Certified Nurse Assistant threw a television remote control at them, resulting in the remote hitting their face, there was no documented evidence in the resident's medical chart of any nursing or medical assessment related to the incident. The facility's documentation policy requires that all information related to a resident's care, including incidents and changes in condition, be recorded in the medical record. However, there were no progress notes, body audit forms, or physician assessments documented in the resident's chart regarding the allegation or subsequent evaluation. Interviews with facility staff revealed that such incidents are typically documented in incident reports and kept in a separate file by the Director of Nursing, rather than being included in the resident's medical record. The Social Worker, who was informed of the allegation, did not document an assessment in the medical chart, and the Nurse Practitioner was not asked to assess the resident after the incident. The lack of documentation in the medical record was inconsistent with the facility's own policy and regulatory requirements.