Incomplete Medical Record Documentation Following Resident Death
Penalty
Summary
The facility failed to ensure that all resident medical records were complete, specifically in the case of one resident with multiple complex diagnoses, including severe cognitive impairment, encephalopathy, dementia, and palliative care needs. Upon review of the resident's medical record following his death, it was found that there was no documentation explaining the circumstances of his expiration, what occurred prior to his death, or any actions taken to provide life-sustaining measures. The only notes present indicated that the resident had expired and that the body was released to the funeral home. Interviews with the Administrator, DON, and the LPN responsible for the resident's care confirmed that there was a lack of required documentation regarding the incident and death. The LPN acknowledged responsibility for documenting the event but confirmed that no such documentation was present in the medical record. Facility policy requires prompt and detailed documentation of changes in a resident's condition, including observations and actions taken, but this was not followed in this instance.