Failure to Accurately Update Electronic Care Plan Following Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident. Specifically, after a resident experienced a fall that resulted in a head injury, the responsible MDS nurse documented the incident and related interventions on a paper care plan due to an electronic system outage. However, this information was not subsequently transcribed into the resident's electronic care plan, which was the version accessible to staff for ongoing care and reference. The resident involved was an elderly female with significant medical issues, including legal blindness, osteoporosis, repeated falls, and severe cognitive impairment as indicated by a low BIMS score. The fall in question was documented on paper, but the electronic care plan, which staff relied upon, did not reflect the incident or the interventions implemented. The care plan only included general fall risk factors and did not mention the specific fall event or the updated interventions following the incident. Interviews with the MDS nurse and the DON confirmed that the omission occurred because the system was down and the paper documentation was not uploaded into the electronic record. Both staff members acknowledged that falls and related interventions should be included in the care plan and that the facility's process required such updates. The facility's policy on care planning did not specify what should be included in the care plan, and there was no documentation available to confirm recent training for the MDS nurse on care plan development.