Inaccurate Documentation of Choking Incident
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for Resident 266, as evidenced by inconsistencies in documentation related to a critical incident. Resident 266, who had diagnoses including diabetes and dementia, was admitted to the facility and had a physician's order for a low concentrated sweets regular texture diet. On January 19, 2025, the resident was found unresponsive after a choking incident during dinner, which led to life-saving measures being initiated and the resident being transferred to the hospital, where they later expired. The clinical records for Resident 266 lacked documentation of the choking incident, the Heimlich Maneuver performed, and the removal of a full-size meatball from the resident's airway by EMT personnel. The SBAR Communication Form completed by Employee 7 (RN) inaccurately indicated that Employee 5 (LPN) completed the form, further contributing to the inconsistencies. Witness statements from staff members provided details of the incident, including the actions taken by the nurse aide and LPNs, but these were not reflected in the resident's clinical record. An interview with the Nursing Home Administrator and Director of Nursing confirmed the failure of the nursing staff to accurately and consistently document the incident in the resident's clinical record. The lack of documentation and inconsistencies between the nursing notes, SBAR Communication Form, witness statements, and the facility's investigative report highlighted the deficiency in maintaining accurate and complete medical records in accordance with professional standards of practice.
Plan Of Correction
Step 1 - Resident 266 d/c from the facility. Step 2 - To identify other residents that have the potential to be affected, the DON/Designee will review the last 14 days of incident and accident events to ensure the resident's record accurately reflects the resident's status. Step 3 - To prevent this from reoccurring, re-education will be provided by the staff educator/designee to the nursing staff re: ensuring that the documentation in the resident record accurately reflects the resident's status. Step 4 - To monitor and maintain compliance, the DON/designee will complete weekly audits of the resident incident and accident events to ensure that the resident record accurately reflects the resident record. The audits will be completed weekly times 4 weeks and then monthly times 3. The results of the audits will be forwarded to QAPI committee for further review and recommendations.