Incomplete and Inaccurate Medical Record Documentation Following Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident who experienced a fall. After the resident sustained a hematoma and facial discoloration following the fall, the change in condition note indicated that the physician could not be notified at the time, and there was no subsequent documentation in the medical record confirming that the physician was later notified. Although an email from the Medical Director later stated that the physician was notified about the fall, the time of notification was not documented in the medical record. Additionally, the physician's progress note was incorrectly dated, referencing an event that occurred after the date on the note, and no addendum was made to correct the date. Further review revealed that the physician's note called for STAT labs due to the hematoma, but there was no documentation in the medical record that these labs were ordered or completed. The physician later clarified that the STAT order was an error and that the resident was clinically stable, so labs could be done on the regular schedule. The Director of Nursing and Nursing Home Administrator confirmed the incomplete and inaccurate documentation regarding physician notification and follow-up in the resident's medical record.