Failure to Document Change in Resident Condition
Penalty
Summary
The facility failed to document an episode of dizziness and vomiting experienced by a resident with a history of hemiplegia, hemiparesis, and left hand contracture following a cerebral infarction. The resident reported feeling dizzy and vomiting a few days prior, and stated that she informed a registered nurse about these symptoms. However, a review of the resident's nurses' progress notes revealed no documentation of these events on the relevant date. Licensed staff confirmed that such symptoms should have been recorded in the medical record to allow for appropriate follow-up and monitoring. Further review of the resident's care plan indicated that any chief complaint of dizziness should be documented, and the facility's policy on charting and documentation required that all changes in a resident's condition be objectively, completely, and accurately recorded in the medical record. The Director of Nursing confirmed that documentation of episodes and frequency of dizziness was necessary according to the care plan. The lack of documentation resulted in an inaccurate representation of the care provided to the resident.