A Michigan woman was arraigned on June 25, 2024, for falsifying medical records connected to the fall of a resident under her care at a nursing home, announced Michigan Attorney General Dana Nessel. She faces charges of one count of Medical Records-Intentionally Placing False Information on a Chart-Health Care Provider and one count of Vulnerable Adult Abuse-4th Degree.
The defendant, a former Licensed Practical Nurse, allegedly pushed a 93-year-old resident in a wheelchair in a manner contrary to facility safety policy on April 12, 2023. This resulted in the resident falling forward and injuring her head and shoulders. The Department alleges the defendant failed to conduct the required neurological checks on the resident and did not complete an unusual occurrence (UO) document, as mandated following such incidents.
On the morning of April 13, 2023, the defendant allegedly denied any fall had occurred during her shift. However, when advised available video footage would be reviewed, it is alleged that she then prepared a UO with a neurological flow sheet purportedly showing that she had performed neurological tests on the resident from the night of April 12 into the morning of April 13.
Attorney General investigators became aware of the case as a result of a Sentinel Project visit conducted at the facility. The Sentinel Project is an initiative started by the Attorney General to better address vulnerable adult abuse in residential care settings. Under the Sentinel Project model, specially trained investigators make unannounced visits to facilities looking for evidence of criminal abuse or neglect of residents.
The penalty for Medical Records-Intentionally Placing False Information on a Chart-Health Care Professional is four years in prison and/or a $5,000 fine; and the penalty for Vulnerable Adult Abuse-4th Degree is 1 year in prison and/or a $1,000 fine.
“We rely on nurses to provide reliable and compassionate care,” Nessel said. “The failure to follow basic safety procedures, coupled with attempts to avoid detection once an injury has occurred, is behavior that has consequences. My department is committed to protecting vulnerable adults and ensuring those responsible for neglect are held accountable.”
Compliance Perspective
Issue
Nurses are expected to exhibit honesty, accuracy, and integrity in the provision of care, including performing nursing assessments, reporting changes in condition, acknowledging errors in practice and reporting them promptly, accurately charting and reporting, implementing care as ordered, complying with all laws and rules affecting the practice of nursing, and complying with the minimum standards of nursing. Falsification of documents regarding care, incomplete or inaccurate documentation of care, failure to provide the care documented, or other acts of deception or omission raise serious concerns about an individual’s ability to provide safe nursing care and prevents subsequent caregivers from having a complete and accurate picture of the resident’s care and condition. If a fall occurs, the resident must be assessed thoroughly, and the plan of care updated to reduce the likelihood of future falls. The physician should be notified promptly of all falls, and if a change in condition occurs, the physician must be notified immediately.
Discussion Points
- Review policies and procedures for resident safety, including fall prevention protocols, to ensure that they provide evidence-based interventions to reduce injuries and falls. Also review your policies and procedures for reporting and documenting incidents/accidents to ensure they include current requirements.
- Train appropriate staff on your policies and procedures for following standards of care and meeting regulatory requirements for medical record content. Also train appropriate staff on resident safety policies and procedures, documentation, and reporting requirements. Document that these trainings occurred and file the signed documents in each employee’s education file.
- Periodically audit medical records to ensure that documentation is complete, meets standards for content and timeliness, and that entries have not been falsified or erroneously reported in any way. Also audit your incident/accident reports to ensure that the responsible party and physician were notified of events appropriately, that all issues where reporting is required were managed timely with appropriate follow-up, and that documentation is complete.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
