Failure to Document Change of Condition and Maintain Accurate Medical Records
Penalty
Summary
The facility failed to document changes of condition and maintain accurate medical records for multiple residents, as observed during interviews and record reviews. For two residents who were hospitalized, there was no complete documentation of the events leading to their transfers. One resident was transferred to a general acute care hospital for gastrostomy tube placement, and another was transferred for seizure episodes. In both cases, the progress notes lacked a full account of the incidents, including assessments prior to transfer, interventions provided, and communication with the resident or their representative. Staff interviews confirmed that required documentation, such as Situation, Background, Assessment, and Recommendation (SBAR) or change of condition (COC) notes, was missing, despite facility policy mandating such records. Additionally, the facility did not maintain accurate wound documentation for a resident with multiple pressure ulcers and other wounds. The nursing progress notes and wound assessments showed inconsistencies in the number and onset dates of wounds, with some wounds appearing in documentation before their actual onset dates. The treatment nurse and medical records director acknowledged discrepancies, suggesting possible electronic health record system issues. The director of nursing confirmed that wound documentation should accurately reflect the resident's current wounds to ensure proper care planning. Facility policies reviewed indicated that licensed nurses are required to document changes in condition, including assessments, physician notifications, and updates to care plans. Policies also require weekly documentation of wound status and accurate, timely entries in the medical record. The observed deficiencies in documentation and record-keeping did not align with these established policies and procedures.