Failure to Document and Report Resident Fall
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented in accordance with accepted professional standards. Specifically, a nurse (LVN) did not document an incident in which a resident was found on the floor by a hospice aide during the early morning hours. The nurse did not record the fall in the resident's medical record, did not notify the resident's responsible party, and did not complete an incident report as required by facility policy. The nurse stated that she was instructed by the Director of Nursing (DON) not to complete an incident report or document the event, despite being aware of the facility's procedures for reporting and documenting falls. The resident involved had a complex medical history, including diagnoses of cerebral infarction, hemiplegia, hemiparesis, mood and anxiety disorders, Alzheimer's disease, weakness, lack of coordination, repeated falls, and abnormal albumin levels. The resident was receiving hospice services, was at risk for falls, and required substantial assistance with activities of daily living. On the morning of the incident, the hospice aide found the resident on the floor, attempted to seek help, and eventually located the nurse to assist in moving the resident. The nurse assessed the resident and found no injuries but did not document the incident or notify the family as required. Interviews with facility staff and review of facility policy confirmed that the nurse was expected to document the fall, notify the physician and family, and complete an incident report within 24 hours. The nurse admitted to not fulfilling these responsibilities, citing instructions from the DON. The administrator acknowledged confusion among staff regarding reporting and documentation expectations, particularly due to conflicting instructions from the previous DON. The facility's policy clearly outlined the steps to be taken following a fall, including documentation and notification requirements, which were not followed in this case.