Failure to Accurately Document Resident's Change of Condition and Vital Signs
Penalty
Summary
The facility failed to maintain complete and accurate documentation of all services provided to a resident, as well as progress toward care plan goals and changes in the resident's medical, physical, functional, or psychological condition. The resident in question had a complex medical history, including pneumonia, acute respiratory failure with hypoxia, COPD with exacerbation, chronic kidney disease, dementia, and other comorbidities. The care plan required close monitoring of oxygen saturation, prompt notification of the physician for significant changes, and documentation of all relevant assessments and interventions. Despite these requirements, there was a lack of documented evidence regarding abnormal vital signs, specifically low and fluctuating blood pressure readings and oxygen saturation levels below 90%. Multiple nurses admitted during interviews that they did not consistently document abnormal findings, with some stating they only recorded 'good' numbers or did not document unless a significant event occurred. One nurse reported that she would be questioned by facility leadership if she documented 'bad' numbers. There was also a lack of documentation regarding the resident's change of condition prior to the emergency event, and the physician was not clearly notified of the resident's unstable status. The deficiency resulted in an inaccurate depiction of the resident's care and health status, as critical information about the resident's deteriorating condition was omitted from the medical record. The facility's own policies required objective, complete, and accurate documentation of all changes in condition and interventions, but these were not followed. The lack of documentation was confirmed by both record review and staff interviews, and the resident ultimately experienced a severe event leading to death, with emergency responders noting the resident was dead on arrival and had signs of having been deceased for some time.