Failure to Document APRN Assessment Following Respiratory Event
Penalty
Summary
The facility failed to ensure that the medical record for a resident was complete and accurate, specifically lacking timely documentation of a medical evaluation. The resident, who had diagnoses including dementia and COPD, was noted to be alert, oriented, and independent with mobility. The care plan directed staff to assess for changes in respiratory status and notify the physician as needed. On the date in question, the resident was observed with shortness of breath and a low oxygen saturation of 88% on room air, compared to a baseline of 92-95%. A breathing treatment was administered, oxygen was applied, and the resident's oxygen saturation improved to 90%. It was documented that the resident was assessed by an APRN and new orders for nasal oxygen were obtained. However, upon review, there was no documentation of the APRN's assessment in the medical record for that date. The facility's policy required that a progress note be written, signed, and dated for each visit. The Medical Director confirmed that if the APRN had assessed the resident, this should have been documented. The absence of this documentation resulted in an incomplete and inaccurate medical record for the resident.