Failure to Document Abuse Allegation and Required Notifications
Penalty
Summary
The facility failed to ensure that the medical record for a resident was complete and accurate regarding an allegation of abuse. A resident with severe cognitive impairment and a history of falls was involved in an incident where a staff member was alleged to have been verbally abusive and to have placed items around the resident's bed, restricting egress. Although the incident was witnessed by a nursing assistant and later observed by a registered nurse, there was no documentation of the event in the clinical record prior to a social services note made later that morning. The record also lacked documentation that the physician and responsible party were notified of the incident. Facility documentation and staff interviews confirmed that the registered nurse supervisor was aware of the incident but did not write a nursing note or document the required notifications. The facility's own policy required that events, incidents, or accidents involving residents, as well as family notifications, be documented in the medical record. The deficiency was identified through review of records, facility documentation, and staff interviews, which revealed the absence of timely and complete documentation related to the abuse allegation.