Failure to Maintain Accurate and Timely Clinical Documentation After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate, complete, and timely clinical record for one resident following a fall and subsequent transfer to the emergency department. After the resident fell on November 25, 2025, neurological checks were initiated, and 21 assessments were documented as completed. However, the electronic record showed that these neurological assessments were not finalized or locked until January 7, 2026, and 13 of the 21 assessments were not signed as completed until after the resident had already been transferred to the emergency department on November 28, 2025. The lock date, which should represent the point at which documentation is finalized and made read-only, was therefore significantly delayed. Additional documentation issues were identified in the resident’s progress notes and practitioner records. A nursing progress note dated November 27, 2025, and another dated November 28, 2025, both describing the resident as awake, alert, oriented to self, and confused per baseline, were not actually created in the electronic record until November 30, 2025. Furthermore, a CRNP progress note dated November 26, 2025, signed at 5:27 PM, and an amended CRNP note dated November 26, 2025, signed on November 28, 2025, at 6:33 PM, were not uploaded into the resident’s electronic clinical record at all. During an interview, the NHA stated that facility staff were temporarily covering the medical records practitioner’s duties while consultative medical records services were being arranged, during which time these documentation failures occurred.
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