Failure to Document Nursing Assessment After Wheelchair Slide Incident
Penalty
Summary
Surveyors identified a failure to maintain medical records in accordance with accepted professional standards when an incident involving a resident sliding from a wheelchair to the floor was not documented by nursing staff or a physician. The facility’s Charting and Documentation policy, dated 01/2026, requires that all services provided, and any incidents, accidents, or changes in a resident’s condition, be recorded in the medical record. Occupational Therapist Assistant #1 documented on 12/06/2025 at 5:00 PM that Resident #1 was seen sliding from a wheelchair to the floor. However, review of the medical record from 12/01/2025 through 12/30/2025 revealed no nursing or physician documentation indicating that the resident was assessed following this event. Resident #1 had diagnoses including constipation, chronic pain syndrome, a history of falling, and was documented on the 11/22/2025 MDS as having moderately impaired cognition. During an interview, Registered Nurse Supervisor #2 stated that on 12/06/2025 they were informed that Resident #1 had slid from the wheelchair to the floor and that the resident reported they did not fall. RN Supervisor #2 acknowledged they did not write any progress note in the resident’s medical record regarding this incident. In a separate interview, the Director of Nursing confirmed that RN Supervisor #2 had been working at the time and stated that RN Supervisor #2 should have written a nursing progress note in the resident’s medical record. This lack of documentation was cited under 10 NYCRR 415.22(a)(1-4).
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