Failure to Document Podiatry Referral and Family Decisions
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation in the medical record for a resident following a change in condition. The resident, who had severe cognitive impairment, sustained a fragmented fracture of their right foot after rolling out of bed. Despite a referral to podiatry services, the resident was not seen by a podiatrist during their stay. The care plan was not updated to reflect the resident's non-weight bearing status after the fall, as directed by the physician. The resident's electronic medical record (EMR) lacked documentation of attempts to have the resident seen by a podiatrist or any explanation for why the resident was not seen. The Director of Nursing (DON) reported attempts to arrange a podiatry visit, but these were not documented in the EMR. Additionally, the family reportedly declined an emergency room visit, but this was also not documented. The physician confirmed the fracture was minor and did not require urgent podiatry consultation, but the lack of documentation regarding the family's decision and the facility's attempts to secure podiatry services was noted as a concern. The resident was diagnosed with COVID-19 during their stay, which may have impeded their ability to receive outside podiatry services. The facility's policy on documentation requires that all relevant information be recorded, including assessment findings and patient and family education. However, the EMR did not reflect the necessary documentation, leading to a deficiency in maintaining accurate and complete medical records.
Plan Of Correction
R 301 did not experience any adverse reaction to the alleged deficient practice. R301 discharged home with her daughters on 2/28/25 in stable condition. All residents have a potential to be affected by the alleged deficient practice. Policy and Procedure for the Documentation has been reviewed by the DON/LNHA and deemed appropriate. Physician staff Nursing team will be re-educated in regards to the Documentation Policy & Procedure with emphasis on: • Documenting time frame for consults. (Physician) • Documenting communication and education provided to resident/family. (Physician and Nursing) Administrator/DON or designee will conduct Physician and Nursing documentation audits to ensure compliance 3x/week for one month. Findings will be presented to QAPI Monthly x3 and PRN. Administrator/DON will be responsible for sustained compliance.