Incomplete and Inaccurate Documentation of Resident Incidents
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents. In one instance, a nurse did not document a resident's change of condition following an incident where the resident was found on the floor. Although the nurse assessed the resident and notified the responsible party, she did not complete a change of condition form, did not document notification of the nurse practitioner, and did not perform a fall risk evaluation or neuro checks. The nurse relied on another resident's account that the individual was crawling, and therefore did not consider it a fall, despite not witnessing the event herself. The nurse also could not recall if any orders were given by the nurse practitioner. For another resident, there were multiple documentation failures related to incidents of aggressive behavior and a fall. The change of condition form for the aggressive behavior was completed and signed by the DON several days after the incident, with vital signs and other information recorded for a later date rather than at the time of the event. Similarly, the change of condition form for the fall included vital signs and blood glucose readings from dates that did not correspond to the incident, including a blood glucose value from two years prior. The primary nurse did not complete the required documentation at the time of the incidents, and the DON later completed some of the forms after the fact. Interviews with facility staff, including the ADON and DON, confirmed that the nurses involved had been trained on proper documentation procedures, including the need to complete change of condition forms, risk assessments, and to notify appropriate parties. The facility's own policy required that all incidents, accidents, or changes in condition be recorded in the resident's medical record, including notification of family and physicians. Despite this, the required documentation was not completed at the time of the incidents, resulting in incomplete and inaccurate medical records for the residents involved.