Failure to Document G-Tube Stoma Condition in Medical Record
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident by not documenting redness and leaking from the resident's gastrostomy tube (G-tube) stoma in the Progress Notes under Advanced Skilled Evaluation (PN ASE) over several days. The resident, who had a history of chronic respiratory failure with hypoxia, tracheostomy, and was dependent on staff for all activities of daily living, was readmitted with a G-tube in place. A Change in Condition Evaluation noted the presence of redness and leaking around the G-tube stoma, but subsequent PN ASE entries by licensed nurses did not include any documentation of these findings. Interviews with multiple licensed vocational nurses (LVNs) confirmed that it was standard practice to document head-to-toe assessments, including skin assessments, in the PN ASE. The LVNs acknowledged that redness and leaking from a G-tube stoma should have been documented in the skin assessment section, and failure to do so could result in other staff being unaware of the issue. The Director of Nursing (DON) also stated that it was the responsibility of all licensed nurses to document skin issues every shift in the PN ASE to ensure accurate and timely care. A review of the facility's policy and procedure on documentation indicated that each resident's medical record should provide a comprehensive picture of the resident's progress, with all assessments, observations, and services documented accurately and completely. Despite this policy, the required documentation regarding the resident's G-tube stoma condition was missing from the medical record during the specified period.