Incomplete and Inaccurate Medical Record Documentation for Diabetic Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with diabetes, as required by their own policies and professional standards. Specifically, when the resident experienced a low blood sugar level of 58 mg/dL, there was no documentation that a Change of Condition (COC) was initiated, nor was there evidence that the resident's representative was notified of the hypoglycemic event. The facility's policies require that such events be documented, including notification of the physician and the resident's representative, but these steps were not recorded in the medical record. Both the LVN and the DON confirmed during interviews that a COC should have been initiated for blood sugar levels below 70 mg/dL, and acknowledged that the required documentation was missing. Additionally, the resident's medical record contained inaccuracies regarding the timing of vital sign documentation. Vital signs were recorded as being taken after the resident had already been discharged and transferred to an acute care hospital. The DON verified that these entries were made post-discharge, which is inconsistent with accurate and timely recordkeeping practices. The facility's policy mandates that all documentation be objective, complete, and accurate, including the date and time care was provided and the name and title of the individual documenting. These documentation failures were identified through interviews, medical record reviews, and policy reviews. The lack of proper documentation for a significant change in condition and the inaccurate recording of vital signs after discharge had the potential to impact the provision of necessary care and services due to incomplete medical record information.