Incomplete Medical Record Documentation for Resident Toileting
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete, accurate, and readily accessible, as required by professional standards and facility policy. Specifically, there was no documentation in the electronic medical record (EMR) regarding toileting for the resident from the evening through the following morning, despite the resident's need for frequent toileting assistance due to a tendency to attempt getting up without calling for help. The resident experienced an unwitnessed fall during this period, resulting in a skin tear and head injury, and required evaluation in the emergency department due to being on anticoagulation therapy. Interviews with nursing staff revealed that the responsible RN provided toileting assistance twice during the shift in question but failed to document these interventions in the CNA task section of the medical record. Facility policy required documentation of care provided and resident response, with an expectation of at least once-per-shift documentation for toileting. The DON confirmed that staff should offer toileting every two to two and a half hours and document at least once per shift unless something unusual occurs. The lack of documentation meant that the medical record was incomplete and not in accordance with accepted standards.