F0842

E

Inaccurate Fall Documentation and Unsecured PHI During Medication Pass

Tabor, Iowa Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records for a cognitively impaired resident and to ensure that documentation was performed by the nurse who actually conducted the assessment. Resident #4 had severe cognitive impairment with diagnoses of Alzheimer’s disease, non-Alzheimer’s dementia, and depression, and was care planned as high risk for falls with interventions including a bed in the lowest position, bed/chair alarm, and a fall mat. A progress note and unwitnessed fall form, both attributed to Staff V (LPN), documented that the resident was found on the floor by the bed, assessed for vital signs and range of motion, had an abrasion to the mid-left back cleansed, was lifted back to bed with a mechanical lift, and had neuro checks initiated. The neurological flow sheet entries under Staff V’s name further documented detailed neuro assessments, including pupil size/reaction, hand grasps, and speech, at multiple time points.

Interviews later revealed that Staff V did not respond to the initial call for assistance, did not witness the fall, and did not assess Resident #4 at the time of the incident. Staff V stated that Staff W (LPN) had already completed the assessment and returned the resident to bed before she arrived, and that she documented based on Staff W’s report. Staff W confirmed she was the nurse who responded to the CNA’s call, found the resident seated on the floor mat with her back against the bed, completed range of motion and pain assessments with no abnormal findings, and assisted with two CNAs to return the resident to bed. Staff W acknowledged she had Staff V complete the fall and assessment documentation and could not justify why. CNA Staff S reported hearing the bed alarm and the resident calling for help, finding the resident on the floor mat with the bed higher than previously placed, and observing Staff W perform assessments and vital signs, while confirming that Staff V did not assess the resident at the time of the fall. The DON later stated that if the resident was documented as sleeping, staff should not have documented hand grasps and pupil assessments, and that documentation must be completed by the nurse who performed the assessment.

A separate deficiency was identified regarding failure to maintain confidentiality of residents’ records during medication administration. During continuous observation of Staff A (RN) administering medications, the nurse was seen entering residents’ rooms while leaving the laptop computer on the medication cart open and unlocked, with the screen visible, and paper notes containing documentation left face up and readable on the cart. This occurred on more than one occasion while the nurse was away from the cart. The Administrator and DON acknowledged that computers were not to be left open and that documentation papers were not to be left uncovered and viewable by others. The facility’s HIPAA/Privacy Safeguarding and Storing Protected Health Information policy stated that active medical records should not be left unattended in areas where residents, visitors, and unauthorized individuals could easily view them.