Failure to Document Code Event and Resident Death in Medical Record
Penalty
Summary
The facility failed to accurately and completely document the medical record of a resident who experienced a code event and subsequently died in the facility. The resident had multiple diagnoses, including hypertension, anemia, heart failure, dementia, schizoaffective disorder, and a history of COVID-19. On the day of the incident, staff responded to a code in the resident's room, performed CPR, and continued resuscitation efforts until EMS arrived and pronounced the resident deceased. Despite these events, there was no documentation in the resident's nursing progress notes regarding the resuscitation efforts, the code event, or the resident's death. Interviews with nursing staff and the Director of Nursing confirmed that there was no code sheet documentation or detailed note in the resident's chart about the incident. The facility's policy required that all services provided, changes in condition, and incidents be documented in the clinical record. However, a review of the medical record and interviews revealed that these requirements were not met, as there was no record of the code or the resident's death in the clinical documentation.