Failure to Document Falls and Medication Administration in Resident Records
Penalty
Summary
The facility failed to maintain accurate and complete documentation in the electronic medical record for two residents who experienced accidental falls. In the case of one resident, there was no initial documentation of the fall, no record of physical assessments, and no documentation of pain medication administration by multiple nurses. Additionally, there was incorrect documentation regarding the administration of pain medication, with discrepancies between the controlled drug record and the Medication Administration Record (MAR). Nurses involved admitted to being too busy or forgetting to document these critical events and interventions, despite having performed assessments and administered medications. For another resident who experienced a fall, the nursing progress notes lacked documentation of vital signs and range of motion assessments following the incident. Although the nurse reported having performed these assessments, they were not recorded in the electronic medical record. The nurse also failed to complete the required SBAR form for the incident. The nurse attributed the lack of documentation to unfamiliarity with the electronic medical record system. Interviews with the Director of Nursing confirmed that staff were expected to follow established protocols for documentation after falls, including recording assessments, vital signs, and medication administration. However, the required documentation was not completed as expected, resulting in incomplete medical records for the residents involved.