Failure to Maintain Accurate Medical Record Following Resident Fall
Penalty
Summary
The facility failed to maintain an accurate and consistent medical record for a resident with multiple diagnoses, including osteoporosis, anxiety disorder, left hemiparesis, major depression, delusional disorder, history of right shoulder replacement, Parkinson's disease, type II diabetes, and a history of cerebral infarction. The resident was identified as high risk for falls and was cognitively intact. The resident experienced a significant fall resulting in bilateral nasal bone fracture and a soft tissue hematoma, as confirmed by a CAT scan. Multiple staff interviews and documentation revealed discrepancies regarding the presence of footrests on the wheelchair at the time of the fall. The resident and a dietary aide both stated that neither footrest was in place, and the resident's weak leg became caught in the front wheel, causing her to fall face-first. A physical therapy assistant also indicated that the footrests were not in use at the time of the incident. However, the progress note by an LPN documented that the resident's foot fell off the footrest, causing the fall, while the facility's final incident report to the state agency stated that the foot pedals were in place. The LPN who wrote the progress note was not listed as a witness on the incident report. When questioned about these discrepancies, the administrator acknowledged awareness of the inconsistent documentation and related issues. These conflicting accounts and documentation errors demonstrate the facility's failure to maintain an accurate and reliable medical record for the resident.