Incomplete Documentation Following Resident Fall
Penalty
Summary
A deficiency occurred when a nurse failed to maintain complete and accurate clinical records for a resident who experienced a change in condition. The resident, an older female with a history of vascular dementia, muscle wasting, osteoporosis, and weakness, was being assisted from the toilet to her wheelchair by two CNAs when her knees gave out. She was guided to the floor and subsequently assessed by the nurse, who performed a head-to-toe assessment and noted no immediate pain or injury. However, the nurse did not complete a change of condition report, incident report, or notify supervisory staff at the time of the event, as she did not consider the incident a fall. The resident later reported pain in her right lower leg, which was managed with pain medication. Days after the incident, the resident informed her physician about the pain, leading to an x-ray that revealed a nondisplaced proximal fibular fracture. The nurse's failure to document the incident and the assessment in a timely manner resulted in a delay in further evaluation and treatment. The Director of Nursing and Administrator only became aware of the incident after being notified by the resident's nurse practitioner several days later. Facility policy required that all assessments, observations, and services be documented completely and in a timely manner, with late entries clearly indicated. The nurse's omission of required documentation and failure to notify appropriate staff were identified as deficiencies in maintaining accurate and complete clinical records in accordance with professional standards and facility policy.