Failure to Document Resident Fall Incident
Penalty
Summary
A licensed nurse failed to document an incident involving a resident who was found sitting on the floor in her room. The resident, who had a history of stroke, vascular dementia, and mild cognitive impairment, reported to her responsible party that she had fallen and hit her head the previous night, and that two staff members assisted her to get up. The responsible party relayed this information to the Assistant Director of Nursing, who stated there was no report of a fall. When interviewed, the resident confirmed she had lost her balance, fallen, and was helped by staff, but denied any injury. The nurse who found the resident on the floor stated that the resident claimed she had chosen to sit on the floor because she did not have a chair, and the nurse assisted her to a chair without documenting the incident in the clinical record. Another nurse indicated she would have assessed and documented if she had found the resident on the floor. The Director of Nursing stated that any incident of a resident being found on the floor should be documented as a fall, regardless of the resident's explanation. A review of the facility's fall policy did not provide guidance on documentation for such incidents.