Failure to Document Incident in Resident Medical Record
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to maintain accurate and complete medical records for a resident following an incident involving alleged rough handling by a CNA during mealtime assistance. The resident, who had diagnoses of Alzheimer's Disease, aphasia, and cognitive communication deficit, was reportedly shaken and had her tooth struck by a spoon while being fed, as witnessed by another staff member. Although the incident was reported to the DON and a self-report was submitted to the state agency, a review of the resident's progress notes revealed no documentation of the incident in the medical record. The DON confirmed that she expected documentation of the incident to be present in the resident's chart, but it was missing.