Failure to Document Nursing Assessment and Incident Involving Vaping Device
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was found in possession of a vaping device. The resident, who had a history of respiratory failure, asthma, and COPD, was admitted with intact cognitive skills and the capacity to make medical decisions. After the vaping device was discovered, the Licensed Vocational Nurse (LVN) assigned to the resident was informed that a medication or item had been found but did not inquire further about the specific item. The LVN took the resident's vital signs but did not document this assessment or the incident in the resident's medical record. Additionally, the Quality Assurance Nurse (QAN) received the vaping device from a Certified Nursing Assistant (CNA) and passed it to the Social Service Assistant but did not document the event or notify the LVN of the specific item found. A review of the resident's medical records with the Assistant Director of Nursing (ADON) confirmed there was no documentation of the assessment or care provided after the vaping device was found. The facility's policy and procedure required that all services, changes in condition, and care provided be documented in the resident's medical record to ensure communication among the interdisciplinary team. The lack of documentation resulted in incomplete information in the resident's medical record and had the potential for delayed medical interventions.