Failure to Complete Change of Condition Assessment and Documentation
Penalty
Summary
The facility failed to complete a change of condition (COC) assessment in accordance with its policy and procedures for one resident. Specifically, a cognitively impaired resident with diagnoses including diabetes, dementia, and hypertension was observed to have urine with sediments and clumps, which was identified as a significant change from baseline. Despite this observation, there was no documented evidence that a COC assessment was completed at the time the change was noticed, as required by facility policy. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that a COC should have been completed immediately upon identification of the change to ensure timely monitoring and intervention. The facility's policy requires prompt reporting and documentation of signs and symptoms that may represent an acute change of condition, as well as timely notification of the resident, physician, and legal representative. The failure to complete the COC assessment and documentation as outlined in the policy had the potential to delay necessary care for the resident. The deficiency was identified through interviews and record reviews, which confirmed the lack of required documentation and adherence to established procedures.