Failure to Timely Document Resident Altercation and Injury Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents involved in a verbal and physical altercation. Specifically, LVN A did not document the altercation in a timely manner in either resident's progress notes, and both LVN B and RN C failed to document injury assessments for one of the residents in a timely fashion. The documentation of the incident and subsequent assessments was delayed, with some entries being made several days after the events occurred, and in some cases, only after being reminded by other staff members. The residents involved had significant cognitive impairments, as evidenced by their BIMS scores of 4, and relevant diagnoses including dementia with agitation, mood disorder, and cognitive communication deficits. The altercation involved one resident striking another with a walker, resulting in visible redness and pain for the affected resident. Despite the incident, documentation of injury assessments and follow-up was not completed as required by facility policy, which mandates follow-up documentation every shift for 72 hours after such incidents. Interviews with staff revealed that documentation was sometimes delayed due to waiting for supervisory review or simply being forgotten. Staff acknowledged the importance of timely and accurate documentation for ensuring appropriate care, and facility policy required pertinent documentation in nurse progress notes and follow-up entries. However, the failure to document the incident and injury assessments promptly resulted in incomplete medical records for both residents.