Failure to Document Resident Altercations and Required Notifications
Penalty
Summary
The facility failed to ensure that resident medical records were complete and accurate by not documenting resident-to-resident altercations and failing to record notifications to families and physicians for four residents reviewed for abuse. Specifically, an altercation occurred between two residents with dementia/Alzheimer's disease, where one resident struck another on the arm after a verbal exchange. This incident was witnessed by a CNA and a family member, but there was no documentation of the event or of family and physician notification in either resident's medical record. The nurse responsible at the time confirmed that such documentation would typically be included in a nursing note, but it was not done in this case. A similar deficiency was found in another incident involving two additional residents with Alzheimer's disease/dementia. One resident struck another on the thigh after a verbal altercation, resulting in a visible red mark. This event was also witnessed by a CNA, but again, there was no documentation of the altercation or of family and physician notification in the medical records of the residents involved. The administrator acknowledged that a nursing note summarizing the incident and notifications should have been present, but it was not completed. The facility's own policy requires documentation of significant changes in resident condition, including behaviors and notifications, but this was not followed.