Failure to Document Change of Condition in Resident Medical Record
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to document a resident's change of condition, specifically an episode of nausea, as required by facility policy and accepted professional standards. The resident, an elderly female with multiple complex diagnoses including stroke, diabetes, malnutrition, hypertension, anemia, peripheral vascular disease, and end stage renal disease on dialysis, was observed by a speech-language pathologist (SLP) to be different than usual, eating less, and reporting nausea. The SLP completed a 'stop and watch' form and reported the change to the LVN, who acknowledged being informed and stated she notified the physician, but did not recall if any new orders were given or if she documented the event. Review of the resident's medical record confirmed that there was no documentation by the LVN regarding the change of condition or any follow-up actions taken. Interviews with the SLP, the LVN, another nurse, and the Director of Nursing (DON) corroborated that the required documentation was missing. Facility policy mandates that all changes in a resident's medical or mental condition be documented, including details such as assessment data, notifications, and conversations with physicians. The failure to document this change of condition resulted in an incomplete medical record for the resident.