Incomplete Clinical Documentation for Incidents and Injuries
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records in accordance with its own Charting & Documentation Policy for two residents. For one resident with an elopement event, the electronic medical record contained no nurse progress note or assessment regarding the elopement, no description of the event itself, no documentation of staff response, and no record of the resident’s condition after being returned to the facility. Although the resident’s care plan and physician orders were updated the following day to include a wander guard, there was no contemporaneous documentation of the incident in the resident’s chart. The DON later confirmed that this documentation was missing and the Administrator stated she was not aware the incident had not been documented. For another resident with documented Alzheimer’s disease and dementia, whose care plan identified risks for falls and elopement/wandering and included a wander guard, a nurse progress note recorded a healing bruise under the left eye. However, there was no documentation in the resident’s chart explaining how the bruise occurred, nor any follow-up assessment or investigation related to this injury. The DON stated that all incident/accident documentation had been recorded in the facility’s internal risk management system, which does not interface with or carry over into the resident’s electronic medical record, and that assessments related to incidents would therefore not be found in the residents’ charts.
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