Incomplete and Inaccurate Documentation of Falls and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate, complete, and objective medical records for a cognitively impaired resident with multiple diagnoses, including traumatic subdural hemorrhage, COPD, and muscle weakness. The resident’s MDS showed severely impaired cognitive skills and a need for staff supervision with hygiene, showering, dressing, transfers, and walking. On one fall incident dated 1/10/2026, the eInteract Change in Condition Evaluation (CIC) documented that the physician was notified at 12 midnight, even though the fall occurred at 7:15 a.m. and the nurse later stated she actually notified the physician around 7:20–7:30 a.m. Both the LVN involved and the DON confirmed that the documented time of physician notification was inaccurate. The facility also failed to document the interventions of an RN who responded to the same 1/10/2026 fall. The LVN reported that she called an RN, who assessed the resident and called 911 and the physician, but a review of the resident’s progress notes for that date showed no documentation by the RN. The DON confirmed that the medical record did not show that the RN had been notified, had performed a head-to-toe assessment, or had called 911, leaving the record without evidence of the RN’s involvement or actions related to the fall. Additional documentation gaps were identified for prior incidents. For a fall on 11/13/2025, the CIC noted that the resident was found on the floor holding the left side of the head and face and complaining of left hip pain, but did not indicate where the resident was found or who found the resident first; the DON stated this CIC was incomplete. For a change in condition on 5/16/2023, the CIC left blank the date and time of responsible party (family) notification. The facility’s own charting and documentation policy required that all services, changes in condition, events, incidents, and notifications be documented in an objective, complete, and accurate manner, including date, time, person providing care, assessment data, and notifications, which was not followed in these instances.
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