Failure to Document Resident Fall Incident in Medical Record
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for a resident regarding documentation of a fall incident. A resident with multiple complex diagnoses, including metabolic encephalopathy, osteomyelitis, endocarditis, diabetes, heart failure, and other chronic conditions, experienced a fall while attempting to transfer from bed to wheelchair. The fall was witnessed by the resident's son, who was present in the room at the time. The resident had been assessed as having moderately impaired cognition. Despite the fall occurring in the presence of a family member, there was no documentation of the incident in the resident's medical record. Multiple interviews with facility staff, including an RN, the DON, and a Regional Quality Assurance RN, confirmed that the fall was not recorded in the medical record. The lack of documentation was verified by both the DON and the facility administrator, as well as the resident's son, who provided details of the incident.