Inaccurate Documentation of Fall and Investigation
Penalty
Summary
The facility failed to accurately document the details of a fall and the subsequent fall investigation for one resident. The medical record review revealed inconsistencies in the documentation of the fall event, including conflicting dates and times of the incident, discrepancies in the reporting of injuries, and inconsistent notification times for the nurse practitioner and resident representative. Two separate fall investigation reports were completed for the same incident, both indicating the fall was classified as 'with injury,' yet both reports stated there was no injury and no pain. Additionally, the progress note from the nurse practitioner described a small abrasion on the back of the resident's head and right thigh pain, which was not reflected in the fall investigation reports. The care plan identified the resident as being at risk for falls due to multiple medical conditions and medications, but the documentation of the actual fall event and related assessments was not consistent or accurate. The resident involved had multiple diagnoses, including osteoarthritis, atrial fibrillation, diabetes, COPD, bipolar disorder, hypertension, and impaired mobility. The resident self-reported the fall, stating she hit her head and hurt her arm, but the incident reports did not document these injuries. Interviews with facility staff confirmed the existence of two incident reports for the same event and acknowledged that the information in the reports did not match. The Director of Nursing confirmed that the fall was classified as a fall with injury, despite the incident reports indicating otherwise, and explained that the duplication occurred because the first report was accidentally closed before completion.