Failure to Document and Report Resident Head Injury as Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to document and respond appropriately to a resident’s change in condition following a head injury. The resident was admitted with diagnoses including a lumbar vertebral wedge compression fracture, giant cell arteritis, and major depressive disorder, and had moderate cognitive impairment per the MDS. On an evening shift, a CNA and the resident’s family member repositioned the resident in bed; during this maneuver, the resident’s head struck the headboard. The CNA’s written statement indicated she told the family member she would notify the nurse, and the family member initially declined but the CNA stated she would inform the nurse anyway. According to the nurse’s written statement, the family member reported that the resident’s head had hit the headboard when being pulled up in bed. The nurse assessed the resident’s scalp, found no drainage or openings, and confirmed twice with both the resident and family member that the resident was “okay.” However, the nurse documented the incident only on paper and not in the resident’s clinical record or progress notes. There was no documentation of this event as a change in condition, no physician notification, and no monitoring initiated at that time, despite the facility’s policy requiring notification and documentation for accidents or incidents involving a resident. Several days later, the resident developed a severe headache rated 10/10 and dizziness, which led to a change in condition note and transfer to the emergency department. At that time, the family member reported the earlier head injury, and staff, including another nurse and a physical therapist, were unaware of the prior incident because it had not been entered into the clinical record. Interviews with nursing staff, the DON, and the Administrator confirmed that the incident on the earlier date was not documented in the resident’s medical record, the physician was not notified, and the resident was not monitored following the head injury, contrary to the facility’s written policy on changes in a resident’s condition or status.
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