Failure to Timely Document Nursing Assessments Following Abuse Allegations
Penalty
Summary
The facility failed to ensure that nursing assessments were completed and documented in the clinical records at the time allegations of abuse were reported for two of three sampled residents. In the first case, a resident with cognitive impairment and a history of non-compliance reported to a family member that a nurse aide had physically abused them, resulting in visible bruising on both forearms. Although the incident was reported and an assessment was said to have been performed, there was no contemporaneous nurse's note or documentation of the assessment in the clinical record. A late entry was created by the DON two weeks after the incident, but the original assessment and documentation were missing at the time of the event. In the second case, another resident with psychiatric diagnoses reported to a social worker that a nurse aide had physically and verbally abused them. The facility's incident report indicated that there were no injuries and that appropriate notifications and an investigation were initiated. However, a review of the clinical record revealed that no nurse's note or assessment was documented following the allegation. The DON later acknowledged that, despite personally assessing the resident and completing paperwork, she did not document the assessment or the allegation in the clinical record at the time of the incident. Facility policy requires that each resident's medical record contain accurate, complete, and timely documentation of all assessments, observations, and services provided, to be completed no later than the shift in which the event occurred. In both cases, the required documentation was not entered into the clinical record as stipulated by policy, resulting in incomplete records regarding the residents' experiences and the facility's response to the abuse allegations.