Failure to Document Guardian's Concerns Regarding Resident Care
Penalty
Summary
The facility failed to document concerns raised by a resident's guardian regarding the resident's care, specifically related to notification about a scheduled follow-up appointment with an orthopedic physician. The resident, who had diagnoses including fractured pelvis and left arm, anemia, anxiety, dementia, depression, neuromuscular dysfunction of the bladder, and schizophrenia, was admitted with a scheduled orthopedic follow-up. The guardian was not informed of the appointment and only learned of it when another family member visited and found the resident absent. The guardian expressed her concerns to the Administrator and the DON, but there was no documentation of these concerns in the resident's medical record or in the facility's Concern Log. Facility policy requires that all services provided, progress toward care plan goals, and any changes in the resident's condition be documented in the medical record to facilitate communication among the interdisciplinary team. Despite this, there was no record of the guardian's expressed concerns or the facility's response. Interviews with facility leadership confirmed the lack of documentation regarding the guardian's complaints about notification of appointments or other care concerns during the resident's stay.