Failure to Maintain Complete and Accurate Clinical Records After Resident Fall and Hospitalization
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a newly admitted female resident with diagnoses of hyperlipidemia and diabetes, who experienced a fall resulting in a head injury and subsequent hospitalization. After the resident fell, struck her head, and was sent to the emergency room due to excessive bleeding, the facility did not complete an incident report at the time of the event. The initial care plan identified the resident as being at risk for falls, with interventions in place, but there was no immediate documentation of the fall, injury assessment, or actions taken in the clinical record. Nursing progress notes for the relevant period did not contain any documentation related to the fall, and the incident report form remained incomplete until several days later, only after surveyor inquiry. Upon the resident's return from the hospital, the facility failed to ensure that her clinical record included hospital documentation from the emergency room visit. Interviews with staff revealed confusion regarding responsibility for documentation and incident reporting, as well as a lack of clarity about protocols for post-fall neurological assessments. The charge nurse on duty did not document the resident's return from the hospital or complete required neurochecks, and the hospital discharge paperwork was not immediately obtained or filed in the resident's record. The Director of Nursing later retrieved the hospital records through an online portal, but this was not done at the time of the resident's return. Observations and interviews confirmed that the resident had visible injuries, including a large bruise and sutures above her eyebrow, and that staff were aware of the fall and subsequent hospitalization. However, the lack of timely and complete documentation, including incident reports, injury assessments, and hospital records, constituted a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards. This deficiency was identified through interviews, record reviews, and direct observation.