Failure to Maintain Accurate Admission Documentation for Resident with C. diff History
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident who was admitted with a recent history of Clostridium difficile (C. diff) infection. Although the resident had completed a course of oral vancomycin and their diarrhea had resolved prior to admission, the medical record lacked an admission note and documentation of nurse-to-nurse communication regarding the resident's condition at the time of transfer from the hospital. The admission screening was completed on a handwritten form, but this form was not scanned into the electronic medical record and was instead destroyed. As a result, there was no documentation in the resident's record to clarify the resident's status or the transmission-based precautions needed upon admission. Interviews with nursing staff revealed that the admission nurse was responsible for entering an admission note or scanning handwritten notes, but this was not done. Staff acknowledged that the information was not documented in the electronic record, and the director of nursing confirmed that facility policy required such documentation to ensure a complete medical record. The administrator also stated that staff were expected to maintain complete records to support quality care. The facility's own policy emphasized the need for timely and accurate documentation reflecting the resident's condition and care provided.