Incomplete Clinical Documentation During Resident Change of Condition
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident who experienced a significant change in condition. On the date in question, the resident, a male with multiple complex diagnoses including Type 1 Diabetes, End Stage Renal Disease, and Congestive Heart Failure, was transferred to the hospital after experiencing hypoglycemia. Documentation in the clinical record was incomplete, as the times for five blood glucose monitoring tests, three medication administrations, and contacts with the nurse practitioner and emergency medical services were not recorded. Interviews with facility staff confirmed that it is required practice to document the date, time, drug, and dose when administering medications, and to record the timing of significant events in the medical record. Staff acknowledged that failure to document these details could result in confusion for subsequent shifts and potentially lead to medication errors. The nurse responsible for the resident's care on the day of the incident admitted to usually documenting at the end of the shift and was unable to explain the omission of documentation for that day. Review of the facility's policy on clinical documentation emphasized the importance of objective, chronological, and complete entries, including the time of care and services provided. The policy also outlined procedures for late entries and corrections, underscoring the expectation that all significant events and care provided should be documented promptly and accurately. The lack of complete documentation in this case was inconsistent with both facility policy and accepted professional standards.