Failure to Document Abuse Allegation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that an allegation of abuse and neglect involving a resident was completely documented in the clinical record. The resident in question had multiple complex diagnoses, including pathological fracture, muscle weakness, dysphagia, heart failure, metastatic cancer, anxiety disorder, and moderate cognitive impairment. Care plans indicated the resident was resistant to care and had a history of behavioral issues such as refusing care, yelling, hitting, and spitting at staff. Despite these factors and an allegation of abuse by a staff member, there was no evidence in the clinical record that the incident was documented as required. Interviews with nursing staff and the Director of Nursing confirmed that facility policy and their expectations required documentation of abuse allegations in the progress notes, including details such as the time of the incident, what was said, actions taken, and notifications made. The DON acknowledged that no progress note or specific documentation about the incident was entered into the clinical record, which did not meet facility expectations or policy. A review of the facility's documentation policy further confirmed the requirement for a complete account of resident care and incidents in the medical record.