Incomplete Documentation of Resident's Medical Records
Penalty
Summary
The facility failed to ensure that clinical records were complete and accurately documented for a resident, leading to a deficiency. The facility's policy required documentation to be objective, complete, and accurate. However, for one resident with Crohn's disease, diabetes, and hemiplegia, there was no documented evidence of assessments conducted by a registered nurse and the Director of Nursing, nor the physician's orders to send the resident to the hospital. The resident's family expressed concerns about the resident's condition, suspecting a stroke, but the assessments and subsequent physician's orders were not recorded in the clinical record. The registered nurse involved admitted to forgetting to update the electronic medical record with her assessments and the physician's orders. The Director of Nursing also confirmed the lack of documentation. The physician indicated that he was not aware of why the resident was not sent to the hospital as ordered. The Regional Director of Clinical Services confirmed the absence of documentation and noted that the nurse had been asked to write a statement after a family grievance was raised. This lack of documentation violated the facility's policy and state regulations, resulting in a deficiency.
Plan Of Correction
1. Resident 2 no longer resides in the facility. 2. DON/Designee will review progress notes and 24-hour report daily to ensure complete documentation of resident's assessments, Physician notification, and Resident representative is completed in the medical record. 3. The Director of Nursing/Designee will educate Registered nurses on the importance of documenting complete assessments, Physician notification, orders received by the Physician, and updating of resident's representatives in the medical record. 4. The Director of Nursing/Designee will audit daily by reviewing progress notes and the 24-hour report to ensure complete assessments, Physician notification, orders received by the Physician, and resident Representatives notification is documented in the medical record. This audit will be completed daily 5 times for two weeks, then three times a week times 2 weeks, then weekly times two weeks, then monthly times two months. Results of the audits will be reviewed at the Quality Assurance meetings until substantial compliance has been met. 5. The completion date will be 02/11/2025.