Incomplete and Inaccurate Clinical Record Documentation Following Resident Incidents
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for two residents. For one resident with epilepsy, obesity, and dysphagia, an incident occurred in which another resident inappropriately touched her. While immediate actions were taken to separate the residents and assess for injuries, documentation in the clinical record was incomplete, lacking detailed information as required by facility policy. The care plan was updated days later, but the initial documentation did not fully capture the assessment, interventions, and communications as outlined in facility procedures. For another resident with encephalopathy, depression, and alcohol dependence, an incident was reported where the resident was found outside the facility after allegedly climbing out of a window. Although the resident had a history of wandering risk, assessments were inconsistent, with some indicating risk and others not. The care plan included interventions for monitoring and documenting wandering behavior, but documentation was not accurate or complete regarding the incident. The DON confirmed that the facility failed to ensure accurate and complete documentation for both residents following these incidents.