Failure to Document Vital Signs After Resident Fall and Change of Condition
Penalty
Summary
The facility failed to ensure accurate documentation of vital signs during a resident’s change of condition following a fall. Resident 2, who had diagnoses including metabolic encephalopathy, dementia, and difficulty walking, and who required partial to moderate assistance with ADLs and was incontinent of bowel and bladder, experienced an unwitnessed fall. A Change of Condition Evaluation dated 12/25/2025 documented that the resident was found sitting on the lobby floor with blood on her face, but there was no documentation of vital signs at that time. A subsequent Change in Condition Progress Note dated 12/26/2025 recorded that the resident was found on the floor by the nursing station with a quarter-sized cut on the forehead that was actively bleeding and that paramedics were called and the resident was transferred to a general acute care hospital via 911, again with no vital signs documented in the clinical record during this change of condition. In a telephone interview, RN 1 stated that the resident had an unwitnessed fall at change of shift and that he was able to assess and monitor the resident’s vital signs during the change of condition but did not document those vital signs in the clinical record. RN 1 acknowledged that he should have documented the vital signs to depict the resident’s accurate well-being after the fall. In an interview, the DON stated that RN 1 should have documented the assessments and monitoring during the change of condition, including current vital signs, to reflect the resident’s accurate well-being after the fall and to determine her condition and/or deterioration, and affirmed that it was the responsibility of nursing staff to ensure residents’ records are complete. The facility’s policy on Documentation in Medical Record required that medical records contain enough information to provide a picture of the resident’s progress and that nursing staff document accurate, relevant, and complete assessments and observations at the time of service, which was not followed in this instance.
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