Failure to Document Abuse Allegation and Fall Event in Medical Record
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for a resident who alleged physical abuse and was found on the floor. According to the facility’s own incident reporting and investigation for a facility-reported incident, the resident alleged that a staff member answered the call bell and hit the resident on the head. Witness statements obtained during the facility’s investigation indicated that the resident was later found sitting on the floor of the room at approximately 11:40 PM. The allegation was reported to the State Agency and local police, and the facility conducted an investigation and submitted a follow-up report, but they were unable to verify that the resident was struck on the head as alleged. When surveyors reviewed the resident’s medical record, there was no documentation of the resident’s allegation of physical abuse, no notation that the resident had an unwitnessed fall or was found sitting on the floor, and no related assessments or interventions documented in response to these events. An incident report dated the same night indicated the resident was observed sitting on the floor next to the bed, but this document was labeled as privileged, confidential, and not part of the medical record. A skin assessment completed the following day documented no current tissue injury and no skin issues, but did not indicate the reason the assessment was performed. Thus, the medical record lacked required entries regarding the allegation of abuse, the fall event, and any clinical assessments or interventions associated with those events.
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