Failure to Document Resident Fall and Acute Pain
Penalty
Summary
A deficiency occurred when staff failed to document a reported fall and associated acute pain for a resident. The resident reported falling onto her right knee while being assisted in the bathroom by two staff members, resulting in immediate pain. Despite the resident's report and the nursing supervisor's assessment of pain, there was no documentation or assessment information in the medical record for the date of the incident. The last progress note was from the previous day, and no new documentation appeared until the following afternoon. Interviews revealed that the nursing supervisor assessed the resident and communicated the incident to both the outgoing and incoming nurses, instructing them on necessary actions. However, neither nurse completed the required documentation, assessment, or incident report. Each nurse assumed the other would handle the post-fall protocol, resulting in a lack of recorded assessment, notification, or follow-up in the resident's chart, as confirmed by facility leadership.