Failure to Document Resident Altercation and Subsequent Clinical Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for two residents involved in an altercation. An investigation file regarding an alleged abuse incident on 2/14/26 documented witness statements from two nurse aides, one reporting that Resident #2 hit Resident #1, and another reporting that both residents were hitting each other. Nurse #1, who was assigned to both residents that day, stated she had been informed that Resident #1 hit Resident #2 and that Resident #2 hit Resident #1 back. She reported she checked both residents, saw no injuries or marks, but did not document the altercation or her assessment in either resident’s medical record. The Administrator stated that Nurse #1 should have made a notation in each resident’s record that they had been involved in an altercation. The deficiency also includes the lack of documentation by a Physician Assistant (PA #1) following an assessment of Resident #1 after the same altercation. On 2/17/26, Resident #1 was noted on a skin audit report to have bruising to the cheek area below the left eye. PA #1 reported that she assessed Resident #1 after staff reported the altercation and the bruise, recalling that the resident’s eye was not painful or shut, there were no vision problems, and the resident stated she had been hit in another room without giving details. PA #1 acknowledged that she did not document her assessment in Resident #1’s medical record. The Administrator reported that PA #1 should have made a notation in the record about this assessment following the bruised eye and altercation.
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