Failure to Document Resident-Reported Fall and Assessment
Penalty
Summary
The facility failed to maintain complete and accurate medical records by not documenting a resident-reported fall and subsequent nursing assessment. A resident with Alzheimer’s disease and a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment, had been admitted with diagnoses including a subsequent encounter for fracture. On the date of the incident, an RN responded to a scream from the resident’s room and found the resident in bed, who stated she had fallen. The RN reported that the resident appeared disoriented and was unable to provide further details about the alleged fall. The RN stated she conducted a thorough assessment of the resident’s body and found no signs of injury, but she did not document the resident’s report of a fall or the assessment in the medical record. During later review of the clinical record by two LVNs and the DON, no documentation of the reported fall or related assessment could be found. The DON and RN both acknowledged that facility policy requires documentation of all incidents, changes in condition, and events involving the resident, and that this documentation was not completed. As a result, the medical record did not reflect the resident’s reported change in condition as required by the facility’s charting and documentation policy.
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