Failure to Document Change in Condition and Physician Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident, as required by accepted professional standards. A resident with a history of hemiplegia, COPD, respiratory failure, and a tracheostomy experienced a significant change in condition, including hypoxia with pulse oximetry readings between 78 and 80 percent, which did not improve above 90 percent despite interventions such as suctioning and increased oxygen. Staff, including an LPN and an RN, responded by notifying the physician and obtaining orders for a STAT chest x-ray, CBC, CMP, and sputum culture. Despite these actions, there was no documented evidence in the resident's clinical record explaining the reason for obtaining the physician's orders or describing the change in the resident's condition on the date in question. Both the LPN and RN stated in interviews that they had communicated and acted upon the resident's declining status, but a review of the clinical record confirmed the absence of required progress notes or documentation regarding the incident. The Nursing Home Administrator and Director of Nursing also confirmed the lack of documentation.