Failure to Document Resident Abuse Allegation and Related Assessments in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a cognitively intact resident with multiple psychiatric diagnoses, including dementia with agitation and psychotic disturbance, anxiety, and bipolar disorder. The resident’s admission record and MDS showed he was cognitively intact, with a BIMS score of 15. On or around late September, the resident reported to staff that a CNA had yelled at him when he complained about his roommate’s urinal being left in the bathroom, and he stated that the interaction was upsetting to him. In a typed interview statement, the resident reported that the aide spoke to him in a way he did not like, but he did not remember the aide’s name and stated he was not scared and felt safe in the facility. A CNA’s written statement documented that the resident described arguing with a specific CNA about the urinal being left in the bathroom, that he had removed it and thrown it on the floor, and that the CNA was screaming at him until an RN intervened. The CNA also documented that the resident appeared fearful and stated he would protect himself from the aide if necessary, and that she immediately reported the incident to the facility abuse coordinator. Despite these reports and the internal investigation, a review of the resident’s electronic medical record for the period surrounding the alleged incident showed no documentation of the resident’s complaint, the alleged verbal altercation, or any related behavioral episodes such as yelling or verbal aggression by either the resident or staff. Interviews with the DON and NHA confirmed that allegations of staff yelling or swearing at residents were documented only in the facility’s incident reporting system and on internal risk management forms, which are not part of the resident’s medical record. The DON stated she was unsure whether such accusations would be documented in the resident’s progress notes and indicated that staff would definitely document if a resident yelled or swore at staff, but not necessarily if staff were accused of yelling at a resident. The NHA stated that the facility did not document the resident’s initial accusation in the medical record and that related information was kept in an investigative file separate from the record. This practice resulted in the absence of any documentation in the resident’s electronic medical record regarding the allegation, the resident’s psychosocial status, or any follow-up assessments during the relevant time frame, contrary to accepted professional standards for nursing documentation as described by the American Nurses Association.
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