Incomplete Clinical Record Documentation Following Resident Fall
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for one resident. An admission MDS assessment indicated that the resident was cognitively impaired, dependent on staff for daily care, and had a history of falls. On the day of the incident, the resident experienced a fall and sustained a skin tear, with subsequent complaints of shoulder pain. Although a registered nurse assessed the resident following the fall and documented the assessment in the facility's investigation documents, this assessment was not included in the resident's clinical record. The Nursing Home Administrator confirmed that the investigation documents were not part of the clinical record, resulting in incomplete documentation for the resident.