Incomplete Documentation of Fall and Behavioral Incident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident, as required by accepted professional standards. Specifically, documentation was missing or incomplete regarding a fall, subsequent assessments, and behavioral incidents. The resident, an elderly female with a history of stroke, gout, and hypertension, experienced a fall that was not fully documented in terms of time, location, pain assessment, skin/injury assessment, or physician orders for monitoring and neuro checks. The SBAR Communication Form completed by an LVN lacked critical details, and the associated pain and skin assessments were either incomplete or absent in the electronic medical record. Additionally, there was no documentation of a behavioral incident involving verbal aggression toward a roommate and a subsequent room change. The LVN involved in the evening shift acknowledged not documenting the verbal aggression or the room change, stating she did not consider it necessary at the time. The Director of Nursing confirmed that such events, including changes in condition and behaviors requiring intervention, should be documented in the medical record to ensure appropriate monitoring and interventions. Review of facility policy indicated that all healthcare professionals are responsible for prompt and appropriate entries in the medical record, including licensed nurses' notes and other assessments. The lack of documentation for the fall, associated assessments, physician feedback, and behavioral incidents resulted in incomplete clinical records for the resident.