Failure to Document Alleged Abuse Incident in Resident Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records regarding an alleged abuse incident involving one resident. The resident had diagnoses including non-Alzheimer’s dementia, anxiety disorder, and muscle weakness, with a BIMS score of 8 indicating severe cognitive impairment. According to a written statement by an LPN (Staff A), a CNA (Staff B) reported that two CNAs (Staff C and Staff D) were assisting the resident to his room when the resident was talking and Staff D told him to shut up and be quiet. Staff B further reported that she saw Staff D pinch the resident’s lips together. Staff A did not witness the pinch but stated she heard what was said to the resident and, when she looked up from her charting, she saw Staff D’s hand moving away from the resident’s face. Despite this alleged incident, review of the resident’s progress notes showed no documentation of the event that occurred on that date. The facility had submitted a self-report of an allegation of abuse, but there was no corresponding entry in the resident’s medical record describing the incident. Additionally, the facility did not have a policy on maintaining accurate and complete resident records. A regional nurse consultant confirmed there was nothing charted in the resident’s record regarding the incident and that there was no incident report of any type, demonstrating the lack of required documentation for this event.
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