Failure to Document Physician Notification After Resident Change in Condition
Penalty
Summary
The facility failed to maintain proper clinical documentation for one resident by not recording the notification of a change in condition to the attending physician and psychiatrist. Specifically, a resident with a history of traumatic brain injury, epilepsy, alcohol abuse, and major depressive disorder exhibited verbal and physical aggression, which was documented in the progress notes. However, there was no documentation that this incident was reported to the resident's physician or psychiatrist as required. During an interview and record review, the DON confirmed that although the incident was verbally communicated to the primary care physician and psychiatrist, it was not documented in the resident's clinical record. The facility's policy requires that changes in a resident's medical or mental condition be reported and documented. The lack of documentation could disrupt the chain of communication among staff and providers.