Failure to Maintain Accurate Medical Records and Post-Fall Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents who experienced falls. For one resident with moderate cognitive impairment and multiple comorbidities, there was no documentation in the medical record regarding a fall that occurred during a mechanical lift transfer, despite staff interviews confirming the incident. The resident's representative was informed of the fall, but was told that an incident report could not be found. Nursing staff reported that documentation related to the fall, including risk management and progress notes, was either missing or had been deleted from the record. Additionally, the care plan was not updated following the fall, and the nurse practitioner was not notified of the incident. For another resident, who was cognitively intact and had several chronic conditions, the facility's incident report indicated a fall resulting in cervical spine fractures and subsequent transport to the emergency room. However, the nurse practitioner reported not being notified of the fall or the need for hospital transport, despite facility documentation stating otherwise. Review of facility policy showed that required actions after a fall, such as assessment, documentation, incident reporting, and care plan review, were not consistently followed for these residents.