Failure to Document Alleged Abuse Incidents in Clinical Records
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for three out of five residents reviewed, specifically by not documenting incidents of alleged verbal abuse in the residents' clinical records. For one resident, who was cognitively intact as indicated by a BIMS score of 14, there was no clinical record documentation of an incident where the resident reported being verbally abused by a dietary staff member. Although the event was recorded in a facility synopsis and statements were obtained, the clinical record lacked any reference to the incident. Interviews with the director of nursing and the administrator revealed inconsistent practices and understanding regarding the documentation of such incidents in the clinical record, despite facility policy requiring accurate and complete records for each patient. Similarly, for two other residents, staff failed to document separate incidents of alleged verbal abuse by an LPN in their clinical records, even though written statements about the events were collected by facility staff. Interviews with nursing staff and the director of nursing confirmed that allegations of abuse should be documented in the clinical records, but this was not done. The lack of documentation was acknowledged by administrative staff during the survey, and no additional information was provided before the survey exit.