Failure to Accurately Document Resident Injury in Medical Records
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for one resident. A review of the clinical records for a resident who was alert, oriented, and diagnosed with atherosclerotic heart disease revealed inconsistencies in documentation following an incident. The nursing note indicated that the resident reported being pushed by an aide while being put to bed and was observed with a large hematoma on the forehead, for which an icepack was applied. However, facility documentation stated that the resident's skin was intact with no discoloration. An interview with the unit supervisor and registered nurse who assessed the resident immediately after the incident confirmed the presence of the forehead injury, highlighting the discrepancy in the medical record.