Inaccurate Clinical Records for Falls and Psychotropic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate clinical records for one resident, as required by accepted professional standards. Nursing documentation showed that the resident experienced multiple falls in January 2026, including a fall from a chair in the dining room with minor bleeding to the left hand and a separate incident in which the resident stumbled and fell to the knees without injury. The resident was later hospitalized and diagnosed with a hemoglobin of 6.6 and a subdural hematoma, and was readmitted to the facility on February 6, 2026. On readmission, the nursing assessment completed February 6, 2026, inaccurately documented that the resident was alert and oriented x3, had normal gait and balance, and had no falls in the prior three months, despite the earlier documented falls. Additionally, the February 2026 medication review inaccurately indicated that the resident had not received psychotropic medications within the prior seven days, even though physician orders for that month included multiple psychotropic medications: Seroquel, Fluphenazine, Divalproex sodium, Benztropine, and Clonazepam.
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