Failure to Accurately Document Suspected Cause of Resident Finger Fracture
Penalty
Summary
The deficiency involves the facility’s failure to completely and accurately document the suspected cause of a resident’s finger fracture, contrary to its policy requiring that each medical record contain an accurate representation of the resident’s actual experiences. The resident had severe cognitive impairment, with BIMS scores indicating inability to complete interviews and impaired decision-making, and relied on staff to anticipate needs. Facility policy required documentation to be accurate, relevant, complete, and detailed enough to depict the resident’s care and responses. In the days surrounding the fracture, multiple progress notes documented significant behavioral disturbances, including the resident fighting staff during care, yelling, climbing and standing on the bed, striking at staff, appearing to experience visual hallucinations, and being very unsteady and weak. On one day, nursing staff documented that the resident was combative and required redirection and one-to-one care, and that bruising and swelling of the right ring finger were noted, prompting orders for Ativan, Tylenol, and an x-ray. Subsequent notes documented that x-rays were obtained, that there were conflicting radiology reports regarding the presence and location of a fracture, and that the resident continued to use his hand and fingers without signs of pain while buddy taping was ordered and implemented for several weeks. During interviews, the ADON, RN, MS clerk/CNA, and former DON all recalled that the resident had been standing on the bed, flailing his arms and legs, hitting or punching the walls, and being combative while staff attempted to provide care and obtain a urine sample. They indicated that the MS clerk had witnessed the resident punching the wall and that this behavior was believed to be the likely cause of the finger fracture. However, none of the contemporaneous progress notes documented that the resident was hitting or punching the wall, nor did they record this as a suspected cause of the fracture. The lack of specific documentation of the wall-punching behavior and its relationship to the injury resulted in an incomplete and inaccurate medical record regarding the cause of the resident’s fracture.
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