Failure to Document Verbal Abuse Allegation in Resident Medical Record and Risk Management System
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record and risk management documentation for a resident who alleged verbal abuse by a CNA. The resident, who had multiple diagnoses including atherosclerotic heart disease, hemiplegia and hemiparesis following cerebral infarction, dysphagia, paraplegia, hypertension, hyperlipidemia, a history of recurrent pneumonia and falls, and gastrostomy status, was cognitively intact with a BIMS score of 13/15. On a specified date, the resident reported that a CNA told him to "shut the f**k up." The nurse manager responded to the scene, ensured the resident was safe, and immediately reported the allegation to the Administrator, who then went to the resident’s room. Despite these actions, the allegation of verbal abuse was not entered into the resident’s medical record and was not documented in the facility’s risk management system, contrary to facility policy and the Charting and Documentation policy, which required that any events, incidents, or accidents involving a resident be recorded in the medical record. The Administrator acknowledged that all incidents were required to be entered into the risk management system and that this did not occur for this resident. The DON confirmed that incidents, including verbal abuse, should have been documented in risk management and somewhere in the resident’s clinical chart, such as psychosocial progress notes, but no such documentation was found for this incident.
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