Failure to Document Physician Communication and Change of Condition
Penalty
Summary
The facility failed to adhere to its own documentation policy by not recording key clinical information for a resident with diabetes mellitus and hypertension. Specifically, there was no documentation of a follow-up pain score after the administration of a second dose of pain medication, no record of a change of condition (COC), and no documentation of communication with the physician regarding the resident's status. These omissions were confirmed during interviews and record reviews with both a Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who acknowledged the absence of required documentation in the resident's chart and Medication Administration Record (MAR). The facility's policy, dated August 2024, requires that all care, observations, and communications, including those with physicians, be documented completely, accurately, and in a timely manner. Despite this, the resident's chart lacked progress notes, COC documentation, and a physician's order for hospital transfer, as well as a follow-up pain assessment after pain medication was administered. These failures were identified during a review of the resident's records and confirmed by facility staff.