A Pennsylvania nurse formerly employed at a senior living facility has pled guilty to neglect of a care-dependent person and tampering with medical records. A patient under the care of the nurse was left in the lobby of the facility and died hours after suffering a fall and serious head injury.
Evidence revealed that the nurse failed to administer a total of eight required neurological checks to the patient after he had an unwitnessed fall at the facility on the night of April 12, 2018. He was discovered deceased just after 7:00 a.m. on the morning of April 13, 2018, as a result of a subdural hematoma.
The defendant presented the facility staff with falsified documentation indicating that she had performed neurological evaluations throughout the evening. Had they been performed, these neurological checks would have indicated the severity of the patient’s injuries and steps could have been taken to save his life.
The nurse was sentenced to six months under house arrest and may not seek reinstatement of her license or work in a care facility/home during her five-year supervision period.
Pennsylvania Attorney General Josh Shapiro stated, “We have several active and ongoing investigations into long-term care facilities and nursing homes across Pennsylvania, and will hold anyone who knowingly neglects a care-dependent person in Pennsylvania accountable.”
Issue:
Nursing staff should be knowledgeable of standards of care, and the facility’s policies and procedures for implementing them. When standards of care policies and procedures are not followed, substandard quality of care may result for residents of the facility. All clinical staff must be knowledgeable of their responsibility to follow standards of care in order to meet resident’s individualized needs, and to provide accurate and complete documentation of the care they provided. Falsifying medical records can be viewed as fraud, and quick action should be taken when falsified medical records are discovered.
Discussion Points:
- Review your policies and procedures on standards of care and documentation of medical records. Update as needed.
- Train all nursing staff on your policies and procedures for standards of care. Additionally, train all clinical staff on your policies and procedures for documentation in medical records. 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 and that entries have not been falsified or erroneously reported in any way.
