Failure to Document Ileostomy Care in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate documentation for one of seven residents, specifically regarding the care of a resident with an ileostomy. The facility's policy required documentation in the nurse's progress notes to reflect changes in status, events, or notifications, as well as a narrative entry for episodes such as admission and response to treatment. The resident's admission record noted the presence of an ileostomy and that care was provided, but the physician's order did not include ileostomy care, and the plan of care lacked details about the specific type and size of appliance to be used. Although an LPN reported providing care for the resident's ostomy several times, there was no documentation in the clinical progress notes indicating that ileostomy care had been provided on any date or shift during the specified period. The Nursing Home Administrator confirmed the failure to accurately and appropriately chart the resident's care as required.