Failure to Maintain Complete Medical Records for Resident Falls
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with professional standards for three of four residents reviewed. For one resident, a progress note documented a witnessed fall and initiation of neurological checks, with subsequent notes referencing continued monitoring. However, the facility was unable to produce the neurological check sheets, as they were completed on paper and subsequently lost. Similarly, another resident experienced a fall, with a nursing note indicating neurological checks were started, but the corresponding documentation could not be located. In a separate incident, a progress note indicated that the interdisciplinary team met to discuss a resident's fall and implemented an intervention, but no incident report for the fall could be found. Staff interviews revealed that the nurse on duty at the time of the fall left her position abruptly after the incident, and although she assessed the resident and relayed information to another nurse, the required incident report was never completed. The facility's policy requires that medical records be organized and easily retrievable, but in these cases, essential documentation related to falls and follow-up care was missing.