Failure to Maintain Complete Medical Records for Resident Fall Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records related to resident incidents, specifically regarding a fall experienced by a resident with multiple diagnoses including osteoarthritis, spinal stenosis, anxiety, major depressive disorder, type 2 diabetes, and chronic pain. The resident, who had cognitive impairment, was found on the floor after sliding out of a recliner while being repositioned by a CNA. Although the incident was recorded in the facility's incident and accident log and discussed in a committee review, the documentation was not included in the resident's official medical record. There was no nurse's note, vital signs, assessment, investigation, or follow-up documentation in the medical record regarding the fall. The DON confirmed that accidents and falls were documented in incident reports, which were not part of the medical record, and verified the absence of required documentation for the incident. The facility's Fall Prevention Program policy required assessment, incident reporting, physician and family notification, care plan review and updates, documentation of all assessments and actions, and witness statements when applicable, but these steps were not reflected in the resident's medical record.