Failure to Document Falls and Assessments in Clinical Records
Penalty
Summary
Facility staff failed to follow professional standards of care for two residents by not documenting unwitnessed falls and the subsequent assessments, actions taken, and circumstances of the incidents. For one resident with multiple complex diagnoses, including dementia and cognitive impairment, there was no clinical record documentation of an unwitnessed fall, immediate assessment, or neurological checks, despite a nurse practitioner note referencing the fall and a risk management form indicating actions were taken. The risk management form was not part of the official medical record, and the facility's own policy required documentation of all assessments and actions in the clinical record. In another case, a resident who had previously suffered traumatic injuries experienced an unwitnessed fall resulting in a hip fracture. The only documentation in the clinical record was a provider note stating the resident fell, had pain, and was sent to the emergency room. There was no documentation by nursing staff regarding the circumstances of the fall, the resident's condition at the time, or the assessments performed prior to transfer. The DON confirmed that the expected practice was not followed, and the event synopsis provided was not part of the clinical record. Interviews with nursing staff and review of facility policy confirmed that the standard procedure after a fall includes assessment, documentation in the clinical record, notification of physician and family, and initiation of neurological checks. In both cases, these steps were not documented as required, and the clinical records lacked essential information about the incidents and the care provided.