Failure to Document Resident Decline and Death
Penalty
Summary
Facility A failed to document the decline, death, and disposition of a resident who was under hospice care and had a diagnosis of Alzheimer's disease. The facility's policy requires that the medical record provide a comprehensive account of the patient's health status, care provided, and serve as a legal record. However, review of the electronic medical record (EMR) for the resident showed only a note indicating release to a funeral home, with no documentation of the resident's decline or the circumstances surrounding the death. An LPN who was caring for the resident reported that after administering morphine and returning to the room, the resident was found unresponsive and subsequently pronounced deceased by the hospice nurse. The LPN acknowledged that, due to the situation, they did not document the resident's decline or death as required. The facility administrator confirmed the expectation that nurses document the resident's condition at the time of death and all events leading up to it, which was not done in this case.