Failure to Document Physician and Responsible Party Notification After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to maintain complete and accurate clinical records for a resident who experienced a fall. The resident, an elderly male with diagnoses including a lumbar vertebra fracture, dementia, heart disease, and hypertension, was found on the floor next to his bed after attempting to reach for his bedside table. The progress note documented the fall, the resident's denial of pain or head injury, and the completion of neuro checks, but did not include documentation that the physician or responsible party (RP) had been notified of the incident, as required by facility policy and the resident's care plan. Further review of the resident's care plan and facility policies confirmed that staff were expected to notify the physician and RP following a fall and to document these notifications in the medical record. Interviews with the physician assistant (PA), licensed vocational nurse (LVN), and director of nursing (DON) revealed that the notifications may have occurred, but were not documented in the resident's progress notes. The PA acknowledged that she should have documented the fall and any related evaluation or orders, while the LVN and DON both stated that all relevant information, including notifications, should be recorded in the progress notes. The facility's own policies on physician visits and medical record documentation require that all significant events, such as falls, and any resulting physician notifications or orders, be accurately and timely documented in the resident's medical record. In this case, the lack of documentation regarding physician and RP notification following the resident's fall constituted a failure to maintain clinical records in accordance with accepted professional standards and practices.