Failure to Document Vital Signs and Care for Resident with Declining Condition
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records for a resident with dementia and diabetes who was experiencing a declining condition and was being considered for hospice care. The staff did not document vital signs, updated plan of care, or the treatment and services provided to the resident, despite the resident being in a critical state that required frequent monitoring. The assigned LVN reported checking the resident every hour and performing vital sign checks every two hours during the night shift, but admitted to not documenting these assessments or the resident's condition in the progress notes. There were no recorded vital signs from the morning prior to the resident being found unresponsive, and no progress notes documenting the resident's condition or care for several days before the resident's death. The facility's policy and procedure on charting and documentation required that all services, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record. However, interviews with facility staff, including the MDS nurse and DON, confirmed the absence of documentation regarding the resident's deteriorating condition, the plan for comfort or hospice care, and the care and services provided to the resident and family. This lack of documentation meant that the resident's clinical record did not accurately reflect the care delivered or the resident's status prior to being found unresponsive.