Failure to Maintain Complete and Accurate Clinical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for two residents. For one resident with severe cognitive impairment and multiple diagnoses, there was an unwitnessed fall resulting in a large hematoma and bruising. Although nursing notes indicated that neurological checks were initiated following the fall, no documentation of these checks was found in the clinical record. The director of nursing confirmed the absence of neuro check documentation, attributing it to a transition from electronic to paper records at the time. Paper copies of the neuro checks were later located but had not been scanned into the electronic health record, as the medical records clerk had not prioritized older documents. In a separate incident, another resident with severe cognitive impairment and multiple diagnoses was involved in a resident-to-resident altercation. The facility's investigation indicated that the resident was assessed for physical and emotional concerns, but there was no documentation of these assessments or any progress notes related to the incident in the clinical record. The director of nursing stated that assessments were performed at the time but should have been documented by nursing staff, in accordance with facility policy requiring documentation of incidents, findings, and corrective measures in the resident's medical record.