MDS Nurse G told federal inspectors she had documented Resident #3's fall on paper because "their system was down at the time" but admitted she "had not uploaded it" to the electronic chart that staff rely on for care planning.
The missing documentation meant other staff members had no way of knowing about the fall when reviewing the resident's electronic care plan. MDS Nurse G acknowledged "the information on Resident #3's paper care plan should have been added into her electronic chart."
She explained why the missing fall record mattered: "If anything happened there would be a record you could go back to and see what incident happened and what the goals and interventions were."
Without the fall documented in the electronic system, staff reviewing the resident's care plan would have no indication of fall risk or the interventions needed to prevent future incidents. MDS Nurse G stated that not including a resident's fall history on their care plan "could negatively impact them because people may not know if they were falling and it was a reference to look back on."
The nurse told inspectors she was responsible for reviewing and monitoring care plans "to ensure they had all the required information." Her monitoring process involved "running an order list in the morning to show any orders from the day before and by adding anything that was discussed in the morning meetings that needed to be added."
Despite this responsibility, Resident #3's fall from nearly a month earlier remained documented only on paper, invisible to the electronic system that staff use for daily care decisions.
MDS Nurse G said she had been trained on developing care plans and what should be included when she first started working at the facility. She received this training "through an MDS training" but could not provide inspectors with the date of that training.
When asked about facility policy regarding fall documentation, MDS Nurse G stated the policy required documenting falls "with the goals and intervention and whatever they were going to do to resolve the issue." She acknowledged that "in this situation she did follow the facility policy on paper but needed to uploaded it."
The Director of Nursing was unable to provide any documentation showing that MDS Nurse G had received training on care plan development. During an interview on November 10 at 4:51 PM, the DON "stated she did not have any documentation to provide for training of MDS Nurse G regarding development of care plans and what should be on it."
Inspectors also reviewed the facility's policy titled "Care Planning - Interdisciplinary Team," which had been updated in December 2024. The policy "did not include any verbiage regarding what should be included on the care plan."
The gap between paper documentation and electronic records created a dangerous blind spot in resident care. While MDS Nurse G had technically documented the fall, the information remained trapped on paper, unavailable to nurses, aides, and other staff members who needed to know about the resident's fall risk when providing daily care.
Fall prevention is a critical safety issue in nursing homes, where residents face heightened risk due to medications, mobility limitations, and cognitive impairments. Care plans serve as the primary communication tool between shifts and disciplines, ensuring all staff members understand each resident's specific risks and the interventions needed to keep them safe.
The October 18 fall occurred during a system outage, but nearly a month passed before inspectors discovered the documentation had never been transferred to the electronic system. During that time, staff members consulting Resident #3's electronic care plan would have seen no indication of the recent fall or any updated interventions to prevent future incidents.
MDS Nurse G's admission that she "needed to uploaded it" suggested she understood the requirement but had failed to complete the transfer. The missing documentation represented more than a paperwork problem - it created a knowledge gap that could compromise the resident's safety and care.
The facility's policy on care planning offered no specific guidance about what information should be included, leaving staff to rely on training that the Director of Nursing could not document. Without clear policies or verifiable training records, the facility had no systematic way to ensure that critical safety information like fall history made its way from paper documentation into the electronic systems that guide daily care decisions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avir At River Ridge from 2025-11-10 including all violations, facility responses, and corrective action plans.