Failure to Document Change of Condition After Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, an LVN did not document a required change of condition form in the electronic medical record after a resident experienced a fall. The LVN worked the shift during which the fall occurred and stated that he followed the fall protocol, including assessing the resident, assisting him up, initiating neuro checks, and notifying the physician, responsible party, and DON. However, upon review, there was no documentation of the change of condition form for the incident, despite the LVN acknowledging he was trained and expected to complete this documentation for every fall. The resident involved had multiple significant diagnoses, including type 2 diabetes, end stage renal disease, heart failure, peripheral vascular disease, hypertension, anxiety disorder, and chronic obstructive pulmonary disease. The resident was identified as being at risk for falls due to a history of falls, decreased mobility, and generalized weakness. Facility policy required that all assessments, observations, and services provided be documented accurately and timely in the resident's medical record. Both the LVN and DON confirmed that the documentation protocol was not followed in this instance.