Inaccurate Documentation of Resident Fall Event
Penalty
Summary
The facility failed to maintain accurate medical records for a resident by documenting conflicting and inaccurate information about the circumstances of a fall. The resident was admitted with a history of falling, a humerus fracture, and joint replacement surgery, and was cognitively intact per the admission MDS. On the date of the fall, nurses’ notes documented that the resident attempted to transfer from bed to walker, was observed on the floor at the foot of the bed, and stated she was trying to get to her walker. The resident was then educated to use the call light and request assistance with ambulation. An incident report, marked as privileged and not part of the medical record, described the fall as unwitnessed and recorded that the resident stated she was ambulating to the bathroom using her walker with a CNA present when she lost her balance. Interviews revealed additional, conflicting accounts that were not accurately reflected in the medical record. LPN D stated that when a code purple was called, the resident was already on the floor and that there were mixed stories about how the fall occurred. RN F, who did not witness the fall, acknowledged confusion regarding the documentation discrepancies. CNA E reported arriving at the tail end of the fall and seeing another aide lowering the resident to the floor, with a walker present but not really being used and no gait belt in place. The DON reported that CNA C, who assisted the resident, stated she had helped the resident to a standing position, left her standing while going into the bathroom to get things ready, and then the resident fell. These differing accounts show that the medical record did not accurately reflect the incident as it actually occurred.
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