Failure to Maintain Accurate and Complete Medical Records and Fall Risk Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for a resident, resulting in incorrect documentation and backdating of records by the former Director of Nursing (DON). The DON backdated Fall Risk Evaluations and did not update risk scores after the resident experienced multiple unwitnessed falls. These assessments were not completed in a timely manner and did not reflect changes in the resident's condition, such as prior fall history and subsequent falls, which should have increased the fall risk score to a high-risk category. The DON also failed to ensure that individualized care plan interventions were documented, and the Fall Risk Evaluations remained at a moderate/low risk score despite evidence to the contrary. The Minimum Data Set (MDS) Coordinator inaccurately recorded the resident's fall history in the MDS assessments, failing to thoroughly check all medical records. This led to incorrect coding of fall history and the absence of a timely fall prevention care plan. The resident, a 58-year-old female with moderate cognitive impairment, generalized muscle weakness, difficulty walking, and a history of falls, did not have a fall prevention care plan focus developed for over six weeks after admission. The MDS Coordinator acknowledged these errors during interviews and confirmed that the previous coordinator missed critical information regarding fall history and high-risk medication use. The medical record review showed inconsistencies between the resident's actual condition and the documentation in the clinical record. Despite the resident's history of falls and use of high-risk medications, the care plan did not address fall prevention in a timely manner, and the risk assessments were not updated to reflect changes in the resident's status. The DON and nurses' job descriptions required accurate and timely documentation, which was not met in this case, compromising the integrity of the resident's medical information.