Failure to Obtain and Accurately Document Vital Signs After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe dementia, agitation, and muscle weakness experienced a witnessed fall in the hallway. The resident was noted to be sitting on the floor with their head against the wall and was resistive to a skin check and range of motion assessment. Despite facility policy requiring assessment and documentation of vital signs following a fall, no staff—including nurse aides and the charge nurse—attempted to obtain or record the resident's vital signs after the incident. The resident was subsequently transferred to the emergency department for evaluation. When completing the required eInteract Transfer Form in the electronic health record, the RN Supervisor entered fabricated vital signs into the form several hours after the incident, as the system would not allow the form to be locked and printed without this information. The Director of Nursing confirmed awareness of the falsified documentation and stated that staff are prohibited from such actions. The facility's Change of Condition policy directs that assessment findings be documented and reported to the physician, but this was not followed in this case. A policy on Nursing Documentation was not available for review.