Failure to Document and Report Witnessed Fall
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for one resident who experienced a witnessed fall. Specifically, nursing staff did not document the witnessed fall in the resident's medical record or complete an incident report as required by facility policy. The LPN responsible for the resident's care on the morning of the incident confirmed that, after being called for assistance, she and two CNAs manually lifted the resident from the floor back to bed but did not report or document the event, believing it was not a fall. As a result, there was no record of the incident in the nurses' notes, and administration was not notified at the time. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and had a care plan indicating a high risk for falls and the need for total lift assistance. The incident only came to light after the resident's representative noticed bruising and discoloration, prompting further investigation. The DON later confirmed that the event should have been documented as a fall and that the required documentation and reporting were not completed by the staff involved.