Incomplete Documentation During Change of Condition Event
Penalty
Summary
The facility failed to ensure accurate and complete documentation for a resident who experienced a change of condition (COC) related to constipation, abdominal pain, and other gastrointestinal symptoms. The resident, who had a history of psychosis, muscle wasting, and atrophy, reported not having a bowel movement for two days and complained of abdominal pain, bloating, and discomfort. Despite these complaints and observable symptoms such as abdominal distention and severe pain, the medical record lacked full assessments and documentation of the resident's condition during the COC event. Multiple entries in the resident's medical record, including the Medication Administration Record (MAR), Progress Notes (PN), and SBAR forms, were incomplete or missing critical information. For example, the MAR did not reflect the resident's pain, and the SBAR forms omitted documentation of abdominal symptoms and pain severity. Nursing staff, including LVNs and RNs, acknowledged during interviews that they failed to document key assessment findings such as pain ratings, abdominal assessments, and the presence of coffee-ground emesis. These omissions were contrary to the facility's policies and procedures, which require objective, complete, and accurate documentation of all changes in a resident's condition and the care provided. The Director of Nursing (DON) confirmed that licensed nurses were expected to perform and document full assessments when a resident experienced a COC, emphasizing that missing documentation could affect resident care and communication among the care team. The facility's policies specifically state that all services, changes in condition, and assessments must be thoroughly documented to facilitate communication and ensure appropriate care planning.