Failure to Maintain Complete and Accurate Clinical Records After Resident Falls
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for three residents, as required by accepted professional health information management standards. For one resident, after being found on the floor and sent to the hospital for evaluation, there was no documentation in the progress notes regarding the date and time the resident was found, sent out, or returned to the facility. Interviews with staff confirmed that documentation of the incident and subsequent actions was incomplete, despite facility policy requiring thorough documentation of such events. Another resident reported a fall and sustained a laceration, but the care plan was not updated to reflect this change in condition. The resident's fall risk evaluation indicated a high risk for falls, and the facility's policy required care plan updates after any fall or change in condition. However, review of the care plan showed no revisions following the incident, indicating a failure to follow established protocols for documentation and care planning. A third resident experienced an unwitnessed fall, but no progress note was entered regarding the incident. The DON acknowledged witnessing the resident on the floor and initiating the required assessments and incident report, but admitted that a progress note was not completed as required. Facility policies reviewed by surveyors clearly outlined the need for timely and thorough documentation of incidents, assessments, and care plan updates, which were not followed in these cases.