Failure to Document Resident Altercation and Care Plan Updates
Penalty
Summary
The facility failed to ensure that medical records contained accurate and complete documentation for two residents following an altercation. On the date in question, a certified nursing assistant observed one resident in a wheelchair hitting another resident, who was in bed, on the legs. The incident was reported to the state agency, and subsequent actions included a nurse assessing the resident for injuries, notification of both residents' representatives, and informing local law enforcement and the physician. However, neither resident's medical record included documentation of the altercation, the interventions used to deescalate the situation, physical and psychosocial assessments, or notifications to representatives. Additionally, it was unclear whether care plans were reviewed or revised, as handwritten changes lacked dates and staff initials. Both residents involved had severe cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores and diagnoses of Alzheimer's dementia and memory impairment. The lack of documentation extended to the care plans, which contained undated and unsigned handwritten interventions and changes. The nursing home administrator confirmed that the medical records did not contain documentation of the incident and was unable to verify if care plans had been reviewed or updated due to the absence of clear revision dates.