Incomplete and Delayed Documentation of Fall and Neuro Checks
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident who experienced a fall. The resident was admitted with diagnoses including atrial fibrillation, aortic valve insufficiency, and congestive heart failure, and had a BIMS score of 10/15, indicating moderately impaired cognition. An incident note in the EMR documented that the resident fell out of bed when blankets fell onto the floor and the resident tripped on them, after which the blankets were picked up and the resident was placed back in bed, with no cuts or bruises noted and the physician and son notified. However, this incident note did not include a complete and accurate description of the fall, as it lacked documentation of vital signs and neurological checks at the time of the fall. During interviews, the IDON confirmed that the resident’s medical record was not complete and accurate and that neurological checks should have been documented at the time of the fall rather than two days later. An RN reported being on duty at the time of the fall and described that the resident, who had anxiety at night and transferred independently to the bathroom, was found lying on their stomach near the side of the bed toward the foot of the bed, wrapped in multiple comforters. The RN stated that the resident did not hit their head and that initial and subsequent neurological checks were performed but not documented at the time due to a busy shift, which the RN acknowledged as a mistake. Review of the EMR showed that the neurological checks were not entered into the record until two days after the fall, confirming the incomplete and delayed documentation related to the incident.
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