Failure to Maintain Complete and Accurate Medical Records Following Resident Falls
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, as required by both facility policy and state regulations. For one resident with Parkinson's disease, schizophrenia, anxiety, and generalized muscle weakness, there was no documentation in the clinical record regarding a fall that occurred during personal hygiene care, including the absence of vital signs, assessment of injuries, first aid or treatments administered, notifications to the family and physician, completion of a falls risk assessment, and the signature and title of the person recording the data. The only note present indicated that the family was informed the resident was at the hospital, but did not document the cause for the transfer. Another resident with a history of stroke, muscle weakness, abnormal gait, and previous falls experienced multiple falls, but the clinical record lacked documentation for each incident. Specifically, there was no record of the falls themselves, vital signs, assessments, treatments, notifications, or completion of falls risk assessments. Additionally, there was a lack of documentation regarding the cause of a skin tear and the presence of dressings for injuries, despite the resident disclosing a fall to a provider. The DON confirmed the absence of required documentation for both residents' falls.