Failure to Document Resident Sliding/Fall Event in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records when staff did not document an incident in which a resident slid from a recliner to the floor. Facility policies on Significant Condition Change and Notification and on Charting and Documentation required that all significant changes, including falls, be recorded in the resident record, with charting each shift for 72 hours as needed, and that all pertinent changes in condition be documented concisely, accurately, and completely. Resident #1, admitted with diagnoses including Type 2 diabetes mellitus, heart failure, HTN, hypokalemia, hyperlipidemia, and stage 3 chronic kidney disease, had a care plan identifying potential for falls due to weakness and medication side effects. The resident’s quarterly MDS indicated intact cognition, substantial/maximal assistance needs for toileting, showering, and personal hygiene, and no falls. On the date in question, an LPN documented a fall follow-up note stating the resident had no latent injuries from an earlier fall and that staff should continue to monitor, based on information received in shift report. However, there was no documentation in the medical record of the actual fall or incident itself. An RN later reported that while working that day, the resident did not “fall” but slid slowly out of a recliner onto the floor, did not hit the head, and had no injury, and acknowledged that this sliding event should have been documented. The DON and the Administrator both stated they considered sliding out of a chair to be a fall and expected staff to document such events in the progress notes and, per the DON, to notify the responsible party. Despite these expectations and policies, the resident’s record lacked documentation of the sliding/fall event, resulting in an incomplete and inaccurate medical record.
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