Deficiency in Accurate Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident, leading to a deficiency in maintaining medical records. The resident, who had been admitted with diagnoses including idiopathic conditions, acute failure, and dependence on supplemental support, experienced a change in condition related to decreased food and fluid intake. Despite the situation being assessed and the provider being notified, the clinical record did not accurately reflect the events that transpired, including the initiation of emergency procedures and the calling of Emergency Medical Transport (EMT). The Director of Nursing (DON) confirmed that the clinical record and transfer form did not document the emergency intervention that was administered. The facility's policy on documentation requires that each resident's medical record accurately represent their experiences and include timely and complete information. However, in this case, the documentation was not completed in accordance with the facility's policy, as it failed to capture the critical interventions and notifications made during the resident's change in condition.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Review of resident #4s clinical record. Resident #4 was transferred out to Lakeland Regional Medical Center. Upon record review resident #4 was transferred out and expired, therefore, she no longer resides at Lakeland Nursing and Rehab. Late entry regarding the event was input in Resident #4s clinical record. 2. Identification of other residents having the potential to be affected: Quality review of code blue events to ensure record contains documentation of per advance directive order. Review of code blue events for the past 90 days to ensure change of condition, transfer forms, if applicable, MD notification, and resident representative notification. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Director of Clinical Services reeducated on documentation policy. All licensed nurses educated on proper documentation protocols, code blue events, change of condition and transfer forms. Code blue events, change of conditions, and transfer forms will be reviewed in the morning clinical meeting with follow-up as necessary. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Nursing/ Designee to complete quality review of any code blue event to make certain record reflects proper documentation. Audits of code blue events, change of condition, transfer forms, if applicable, MD notification, and resident representative notification. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.