F0842

D

Missing Post‑Fall Clinical Documentation in Resident Record

Hamden, Connecticut Survey Completed on 02-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure complete clinical documentation for a resident following a fall, as required by facility policy and accepted standards. The resident had diagnoses including Alzheimer’s disease, a cervical vertebrae fracture, and a history of back pain, and was care planned as being at risk for falls due to prior falls, weakness, impaired mobility, and impaired safety awareness. On the day of the fall, nursing notes documented that the resident was found on the floor after an unwitnessed fall, initially denied pain when standing, later complained of back pain, and was treated with Tylenol. Subsequent notes described grimacing from lower right back and hip pain and a swollen left ankle, with an APRN ordering portable x‑rays, which later showed osteoarthritis of the left ankle and lumbosacral spine. A later note that evening documented no signs of discomfort and normal vital signs and neurological checks.

The facility’s falls management policy required that, once a resident was identified as stable after an unwitnessed fall in a poor historian, neurological signs and related assessments be documented on a neurological flow sheet for 72 hours, and that documentation be completed for 72 hours to assess for latent injuries. However, there were no nursing progress notes entered for the 11‑7 AM and 7‑3 PM shifts on the day after the fall, during the 72‑hour post‑fall period. Although shift‑to‑shift report sheets and a neurological documentation sheet existed, they were not part of the clinical record, and the missing progress notes for those two shifts meant the resident’s condition and clinical findings were not documented in the medical record as required during that portion of the 72‑hour post‑fall monitoring period.