Incomplete Medical Record Documentation After Resident Fall with Major Injury
Penalty
Summary
The facility failed to ensure that a resident's medical records were complete and accurately documented following a significant incident. A resident with multiple medical diagnoses, including a history of femur fracture, heart failure, and severe cognitive impairment, experienced an unwitnessed fall resulting in a major injury. The fall was documented in an occurrence note, which described the resident being found on the floor with abrasions and subsequently being sent to the hospital. Hospital records confirmed the resident sustained a closed fracture of the left femur as a result of the fall. Despite the occurrence and the resulting injury, there were no documented notes in the electronic medical record (EMR) regarding the fall or the fracture for the period following the incident. This lack of documentation was confirmed by the Director of Nursing during an interview. The deficiency was identified during a review of records for residents at risk for accidents, affecting one of five residents reviewed in this area.