Inaccurate Documentation of Change of Condition and Vital Signs
Penalty
Summary
The facility failed to maintain accurate and timely clinical records for one resident by not ensuring that the documented times for vital signs and the change of condition accurately reflected when these events occurred. Specifically, the resident, who had a history of COPD, paroxysmal atrial fibrillation, and heart failure, experienced chest pain and was administered nitroglycerin as ordered. However, the times recorded for the onset of chest pain, administration of medication, and the taking of vital signs were inconsistent and did not match the actual sequence of events as described by staff interviews and record reviews. Documentation in the resident's medical record showed discrepancies, such as the physician being notified before the documented onset of chest pain and vital signs being recorded at times that did not correspond with the actual events. The facility's policy required that documentation be objective, complete, and accurate, including care-specific details and assessment data. The Director of Nursing and Quality Assurance Nurse both acknowledged that the documentation was inaccurate and did not provide a reliable timeline of the resident's change of condition and interventions.