Failure to Maintain Accurate and Complete Medical Records for Residents with Falls
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two of three residents reviewed for falls. In one instance, a resident experienced an unwitnessed fall while transferring from a wheelchair to a recliner. Although an incident report was completed and a non-skid device was added to the recliner as an intervention, there were no corresponding nursing notes in the resident's electronic medical record documenting the fall or the intervention. The Director of Nursing confirmed the absence of documentation and acknowledged that the intervention was not added to the resident's care plan. In another case, a resident fell from her bed, resulting in a subarachnoid hemorrhage and nasal fractures. The fall investigation was completed and signed by the Director of Nursing, but this documentation was not included in the resident's clinical medical record. The nurse on duty at the time of the fall was on break, and upon returning, only documented what she observed, omitting details of the incident that occurred during her absence. The Director of Nursing, who was present during the fall, did not document the event in the resident's chart, despite being the responsible nurse at the time. Additionally, there were inconsistencies in the documentation of the resident's use of enabler side rails. The care plan erroneously indicated the use of enabler bars for bed mobility, while assessments and therapy notes confirmed that the resident did not use such devices. The Care Plan Coordinator admitted to adding the intervention in error, attributing it to standard practices at another facility. These documentation errors are contrary to the facility's own policies, which require accurate and timely documentation of resident status, incidents, and interventions.